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Catassi G, Marmo C, Gasbarrini A, Riccioni ME. Role of Device-Assisted Enteroscopy in Crohn's Disease. J Clin Med 2024; 13:3919. [PMID: 38999485 PMCID: PMC11242258 DOI: 10.3390/jcm13133919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 07/14/2024] Open
Abstract
Crohn's Disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract, posing diagnostic and management challenges due to its potential involvement of any segment from the mouth to the anus. Device-assisted enteroscopy (DAE) has emerged as a significant advancement in the management of CD, particularly for its ability to access the small intestine-a region difficult to evaluate with conventional endoscopic methods. This review discusses the pivotal role of DAE in the nuanced management of CD, emphasizing its enhanced diagnostic precision and therapeutic efficacy. DAE techniques, including double-balloon enteroscopy (DBE), single-balloon enteroscopy (SBE), and the now-withdrawn spiral enteroscopy, enable comprehensive mucosal assessment, targeted biopsies, and therapeutic interventions like stricture dilation, bleeding control, and foreign body removal. Despite its benefits, DAE carries risks such as perforation, bleeding, and pancreatitis, which require careful procedural planning and a skilled execution. The review highlights DAE's impact on reducing surgical interventions and improving patient outcomes through minimally invasive approaches, thereby enhancing the quality of life for patients with CD. Continuous improvement and research are essential in order to maximize DAE's utility and safety in clinical practice.
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Affiliation(s)
- Giulia Catassi
- Digestive Endoscopy Unit, IRCCS "Agostino Gemelli" University Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
- Pediatric Gastroenterology and Liver Unit, Umberto I Hospital, Sapienza University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Clelia Marmo
- Digestive Endoscopy Unit, IRCCS "Agostino Gemelli" University Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Internal Medicine, Gastroenterology and Liver Unit, "Agostino Gemelli" University Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Maria Elena Riccioni
- Digestive Endoscopy Unit, IRCCS "Agostino Gemelli" University Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
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Han W, Hu J, Wu J, Zhang P, Liu Q, Hu N, Mei Q. Use of double-balloon endoscopy and an endoscopic scoring system to assess endoscopic remission in isolated small bowel Crohn's disease after treatment with infliximab. Therap Adv Gastroenterol 2024; 17:17562848231224842. [PMID: 38250016 PMCID: PMC10799591 DOI: 10.1177/17562848231224842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Background It is unclear how clinical and endoscopic factors affect the attainment of endoscopic remission (ER) in patients with small bowel Crohn's disease (SB-CD) who are infliximab-naïve. Objectives We aimed to identify the effect of different factors on attaining ER using double-balloon endoscopy (DBE) evaluation. Design A single-center retrospective observational study was conducted from 1 January 2018 to 30 November 2022. Among 262 patients who were screened for isolated SB-CD by baseline DBE, 108 patients were assessed for effectiveness during maintenance infliximab therapy by a second DBE evaluation. Methods DBE findings before and after infliximab therapy were compared. ER was defined as a simple endoscopic score for CD (SES-CD) below 3, and segmental ER as SES-CD activity of 0. Multivariate regression with calculations of odds ratios (OR) was used to determine the impact of different factors on attaining ER. Results In all, 41 patients (38.0%) achieved ER. An elevated C-reactive protein at week 6 was independently associated with a decreased probability of ER [OR: 0.86, 95% confidence interval (CI) = 0.75-0.98, p = 0.03]. Segmental ER of the terminal ileum, rather than the proximal ileum, was associated with a higher rate of ER (60.9% versus 38.2%, p = 0.01). High baseline SES-CD (⩾16) was unrelated to overall ER. For patients with disease in the terminal ileum, those with moderate/severe disease were less likely to attain segmental ER than those with mild disease [adjusted odds ratios (aOR): 0.27, 95% CI: 0.09-0.83, p = 0.02]. A large ulcer in the terminal ileum was associated with a lower rate of segmental ER (aOR: 0.18, 95% CI: 0.06-0.56, p = 0.01). Conclusion For infliximab-naïve patients with SB-CD, the overall severity of the endoscopic score was unrelated to attainment of ER. Patients were less likely to attain segmental ER if they had greater endoscopic inflammation or larger ulcers in the terminal ileum.
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Affiliation(s)
- Wei Han
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jing Hu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Juan Wu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Peipei Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qiuyuan Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Naizhong Hu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qiao Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei 230022, China
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Na JE, Kim HS, Hong SN, Song KD, Kim JE, Kim ER, Kim YH, Chang DK. Comparison of an Endoscopic Scoring System and the Simplified Magnetic Resonance Index of Activity in Patients with Small Bowel Crohn's Disease. Gut Liver 2024; 18:97-105. [PMID: 37013455 PMCID: PMC10791503 DOI: 10.5009/gnl220422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/08/2023] [Accepted: 01/17/2023] [Indexed: 04/05/2023] Open
Abstract
Background/Aims The newly derived simplified magnetic resonance index of activity (MARIAs) has not been verified in comparison to balloon-assisted enteroscopy (BAE) for patients with small bowel Crohn's disease (CD). We studied the correlation of MARIAs with simple endoscopic scores for CD (SES-CD) of the ileum based on magnetic resonance enterography (MRE) and BAE in patients with small bowel CD. Methods Fifty patients with small bowel CD who underwent BAE and MRE concurrently within 3 months from September 2020 to June 2021 were enrolled in the study. The primary outcome was the correlation between the active score of ileal SES-CD (ileal SES-CDa)/ileal SES-CD and MARIAs based on BAE and MRE. The cutoff value for MARIAs identifying endoscopically active/severe disease, defined as ileal SES-CDa/ileal SES-CD of 5/7 or more, was analyzed. Results Ileal SES-CDa/ileal SES-CD and MARIAs showed strong associations (R=0.76, p<0.001; R=0.78, p<0.001). The area under the receiver operating characteristic curve of MARIAs for ileal SES-CDa ≥5 and ileal SES-CD ≥7 was 0.92 (95% confidence interval, 0.88 to 0.97) and 0.92 (95% confidence interval, 0.87 to 0.97). The cutoff value of MARIAs for detecting active/severe disease was 3. A MARIAs index value of ≥3 identified ileal SES-CDa ≥5 with a sensitivity of 85% and specificity of 87% and detected ileal SES-CD ≥7 with a sensitivity of 87% and specificity of 86%. Conclusions This study validated the applicability of MARIAs compared to BAE-based ileal SES-CDa/SES-CD.
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Affiliation(s)
- Ji Eun Na
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Hon Soul Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung Doo Song
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Eun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Ho Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Kyung Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kawamoto A, Takenaka K, Hibiya S, Kitazume Y, Shimizu H, Fujii T, Saito E, Ohtsuka K, Okamoto R. Combination of leucine-rich alpha-2 glycoprotein and fecal markers detect Crohn's disease activity confirmed by balloon-assisted enteroscopy. Intest Res 2024; 22:65-74. [PMID: 37939721 PMCID: PMC10850704 DOI: 10.5217/ir.2023.00092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/13/2023] [Accepted: 10/05/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic activity confirmed by enteroscopy is associated with poor clinical outcome in Crohn's disease (CD). We investigated which of the existing biomarkers best reflects endoscopic activity in CD patients including the small bowel, and whether their combined use can improve accuracy. METHODS One hundred and four consecutive patients with ileal and ileocolonic type CD who underwent balloon-assisted enteroscopy (BAE) from October 2021 to August 2022 were enrolled, with clinical and laboratory data prospectively collected and analyzed. RESULTS Hemoglobin, platelet count, C-reactive protein, leucine-rich alpha-2 glycoprotein (LRG), fecal calprotectin, and fecal hemoglobin all showed significant difference in those with ulcers found on BAE. LRG and fecal calprotectin showed the highest areas under the curve (0.841 and 0.853) for detecting ulcers. LRG showed a sensitivity of 78% and specificity of 80% at a cutoff value of 13 μg/mL, whereas fecal calprotectin showed a sensitivity of 91% and specificity of 67% at a cutoff value of 151 μg/g. Dual positivity for LRG and fecal calprotectin, as well as LRG and fecal hemoglobin, both predicted ulcers with an improved specificity of 92% and 100%. A positive LRG or fecal calprotectin/hemoglobin showed an improved sensitivity of 96% and 91%. Positivity for LRG and either of the fecal biomarkers was associated with increased risk of hospitalization, surgery, and relapse. CONCLUSIONS The biomarkers LRG, fecal calprotectin, and fecal hemoglobin can serve as noninvasive and accurate tools for assessing activity in CD patients confirmed by BAE, especially when used in combination.
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Affiliation(s)
- Ami Kawamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Endoscopic Unit, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shuji Hibiya
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Endoscopic Unit, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshio Kitazume
- Department of Radiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiromichi Shimizu
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshimitsu Fujii
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eiko Saito
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Ohtsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Endoscopic Unit, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryuichi Okamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
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Bohra A, Lewis D, Segal JP, Vasudevan A, Van Langenberg DR, Niewiadomski O. Utility of panenteric capsule endoscopy for the detection of small-bowel Crohn's disease in patients with a normal magnetic resonance enterography: A prospective observational pilot study. JGH Open 2023; 7:966-973. [PMID: 38162838 PMCID: PMC10757497 DOI: 10.1002/jgh3.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/09/2023] [Accepted: 11/12/2023] [Indexed: 01/03/2024]
Abstract
Background and Aim Capsule endoscopy allows the direct visualization of the small bowel. We examined the diagnostic utility of a new modality, namely panenteric Crohn's capsule endoscopy (CE), in detecting active small-bowel Crohn's disease (CD) in those with normal magnetic resonance enterography (MRE). Methods We prospectively recruited patients with a diagnosis of CD or suspected small-bowel CD in whom the MRE was normal. Inclusion criteria included abdominal symptoms and abnormal serum or fecal biomarkers. The primary outcome was the detection of active small-bowel CD (measured through the Lewis score [LS]). Secondary outcomes included change in Montreal classification for those with a pre-existing CD diagnosis, change in medical therapy, clinical activity, and biomarkers at baseline and 6 months, and quality-of-life measures. Results A total of 22 patients with a diagnosis of CD or suspected new diagnosis were recruited, with CE complete to the caecum in 21 and 18/21 (86%) showing evidence of active small-bowel CD (LS > 135). Of the patients with a pre-existing diagnosis of CD, 9/11 (82%) had a change in Montreal classification. At 6 months following CE, 17/18 (94%) had clinician-directed change in therapy. This correlated with an improvement in the quality of life (P < 0.05 as per the Short Inflammatory Bowel Disease Questionnaire), a reduction in the Harvey Bradshaw index (median: 7-4, P < 0.001), and favorable CRP and albumin response. Conclusion Crohn's CE is a useful diagnostic test for assessing active small-bowel CD when imaging is normal but clinical suspicion is high. Crohn's CE should be integrated into the diagnostic algorithm for small-bowel CD.
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Affiliation(s)
- Anuj Bohra
- Department of GastroenterologyBox Hill HospitalBox HillVictoriaAustralia
- Department of GastroenterologyNorthern HospitalEppingVictoriaAustralia
- Eastern Health Clinical SchoolMonash UniversityBox HillVictoriaAustralia
| | - Diana Lewis
- Department of GastroenterologyNorthern HospitalEppingVictoriaAustralia
| | - Jonathan P Segal
- Department of GastroenterologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Abhinav Vasudevan
- Department of GastroenterologyBox Hill HospitalBox HillVictoriaAustralia
- Eastern Health Clinical SchoolMonash UniversityBox HillVictoriaAustralia
| | - Daniel R Van Langenberg
- Department of GastroenterologyBox Hill HospitalBox HillVictoriaAustralia
- Eastern Health Clinical SchoolMonash UniversityBox HillVictoriaAustralia
| | - Olga Niewiadomski
- Department of GastroenterologyBox Hill HospitalBox HillVictoriaAustralia
- Eastern Health Clinical SchoolMonash UniversityBox HillVictoriaAustralia
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Na JE, Hong SN, Kim JE, Kim ER, Kim YH, Chang DK. Can balloon-assisted enteroscopy predict disease outcomes in patients with small-bowel Crohn's disease? BMC Gastroenterol 2023; 23:331. [PMID: 37759282 PMCID: PMC10523599 DOI: 10.1186/s12876-023-02892-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/18/2023] [Indexed: 09/29/2023] Open
Abstract
There are limited studies on the endoscopic assessment of disease activity using balloon-assisted enteroscopy (BAE) and its predictive role for long-term outcomes of patients with small bowel Crohn's disease (CD). We sought to investigate the value of BAE as a predictor of long-term outcomes in patients with small-bowel CD. A total of 111 patients with small-bowel CD whose endoscopic disease activity was assessed using BAE based on the small-bowel simple endoscopic score for Crohn's disease (small-bowel SES-CD) at Samsung Medical Center were retrospectively selected from January 2014 to August 2020. The outcome was an evaluation of the risk of surgery according to a small-bowel SES-CD of 0-6 vs. ≥ 7 and endoscopic findings (presence of any ulcer and degree of stricture) using the Cox proportional hazards model. The risk of surgery was significantly increased in patients with a small-bowel SES-CD of ≥ 7 compared to a small-bowel SES-CD of 0-6 [hazard ratio (HR) 6.31; 95% confidence interval (CI) 1.48-26.91; p = 0.013]. In addition, the risk of surgery was significantly increased in patients with stenosis with "cannot be passed" compared to the cases without stenosis (HR 12.34; 95% CI 1.66-91.92; p = 0.014), whereas there was no significance in any ulcer. The present study demonstrated the role of BAE in the endoscopic assessment of disease activity and its predictive value for the risk of surgery in small-bowel CD patients. Further optimization of BAE utilization for the assessment of disease activity is warranted in clinical practice.
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Affiliation(s)
- Ji Eun Na
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
- Department of Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Sung Noh Hong
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Ji Eun Kim
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Eun Ran Kim
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Young-Ho Kim
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Dong Kyung Chang
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
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Hu J, Wu J, Zhang P, Hu N, Mei Q, Wu X, Han W. Evaluation of symptomatic small bowel stricture in Crohn's disease by double-balloon endoscopy. BMC Gastroenterol 2023; 23:247. [PMID: 37475007 PMCID: PMC10360240 DOI: 10.1186/s12876-023-02839-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 05/30/2023] [Indexed: 07/22/2023] Open
Abstract
PURPOSE To assess the efficacy of double-balloon endoscopy (DBE) for the detection of small-bowel strictures in Crohn's disease (CD). METHODS This tertiary-referral hospital cohort study was conducted between January 2018 and May 2022. CD patients with symptoms of small-bowel stricture were enrolled sequentially. All of the patients were subjected to both computed tomography enterography (CTE) and DBE, and their symptoms of stricture were assessed using the Crohn's Disease Obstructive Score (CDOS). The diagnostic yield of DBE was compared to that of CTE, and the relationship between the DBE findings and CDOS was investigated. The factors influencing the DBE diagnosis were examined using Cox regression analysis. RESULTS This study included 165 CD patients. The CDOS scores were higher in 95 patients and lower in 70 patients. DBE detected 92.7% (153/165) and CTE detected 85.5% (141/165) of the strictures. The DBE diagnostic yields were 94.7% (90/95) in the high CDOS patients and 91.4% (64/70) in the low CDOS patients (P = 0.13). Patients with a history of abdominal surgery and abscess had a lower diagnosis rate in the multivariate analysis. CONCLUSION DBE has been demonstrated to be an efficient diagnostic method for detecting small bowel strictures in CD patients. Additionally, there was no difference in the diagnostic yields between patients with low and high obstructive scores.
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Affiliation(s)
- Jing Hu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Hefei, 230022, Anhui Province, People's Republic of China
| | - Juan Wu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Hefei, 230022, Anhui Province, People's Republic of China
| | - Peipei Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Hefei, 230022, Anhui Province, People's Republic of China
| | - Naizhong Hu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Hefei, 230022, Anhui Province, People's Republic of China
| | - Qiao Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Hefei, 230022, Anhui Province, People's Republic of China
| | - Xingwang Wu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, People's Republic of China
| | - Wei Han
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Hefei, 230022, Anhui Province, People's Republic of China.
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Replacing Endoscopy with Magnetic Resonance Enterography for Mucosal Activity Assessment in Terminal Ileal Crohn’s Disease: Are We There Yet? Diagnostics (Basel) 2023; 13:diagnostics13061061. [PMID: 36980368 PMCID: PMC10046927 DOI: 10.3390/diagnostics13061061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Crohn’s disease (CD) is a chronic immune mediated disorder that most commonly affects the small bowel and/or the large bowel. Treatment targets in CD include mucosal healing assessed via ileocolonoscopy and transmural healing assessed through cross-sectional imaging modalities such as magnetic resonance enterography (MRE). More recently, histological healing in CD has emerged as a treatment target, though it is made cumbersome given its reliance on frequent endoscopic examinations. With expert guidelines now recommending regular objective assessments as part of a treat-to-target approach, accurate non-invasive assessment will become increasingly critical. MRE has an established role in the assessment of small bowel CD, with growing data supportive of its ability in detecting disease activity at mucosal and histological levels. This could therefore potentially reduce the need for serial endoscopic assessment. Thus, this review will assess the capacity of individual MRE parameters and MRE indices for detecting mucosal and histological small bowel CD activity. Furthermore, challenging scenarios, such as CD activity detection in post-operative clinical scenarios and abnormal findings in the context of a normal ileocolonoscopy, will be explored.
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Takeuchi K, Inokuchi T, Takahara M, Ohmori M, Yasutomi E, Oka S, Igawa S, Takei K, Baba Y, Kawano S, Yamasaki Y, Kinugasa H, Harada K, Hiraoka S, Okada H. Usefulness of Intestinal Ultrasound to Detect Small Intestinal Stenosis in Patients With Crohn's Disease. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:373-383. [PMID: 35689530 DOI: 10.1002/jum.16038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/17/2022] [Accepted: 05/22/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Double balloon enteroscopy (DBE) with retrograde contrast is useful as a monitoring tool for small intestinal lesions in Crohn's disease (CD), but these are burdensome for patients. Intestinal ultrasound (IUS) can be used with ease in daily clinical practice, but there is less evidence regarding the accuracy of detection of small intestinal stenosis in CD. This study aimed to examine the diagnostic power of IUS for small intestinal stenosis in patients with CD. METHODS The findings of DBE and IUS in 86 patients with CD with small intestinal lesions were evaluated. Using DBE as the reference standard, we examined the detection rate of IUS for small intestinal stenosis. We evaluated three parameters: luminal narrowing, prestenotic dilation, and to-and-fro movement for determining stenosis using IUS. In addition, we compared the characteristics between the stenosis-detectable and stenosis-undetectable groups by IUS. RESULTS Of the 86 patients, 30 had small intestinal stenosis. In IUS findings, when lesions that met two or more of the three parameters were judged as stenosis, the detection rate was 70.0% for sensitivity, 98.2% for specificity, and 88.4% for accuracy. Moreover, there were patients with a younger age at diagnosis (P < 0.05) and more ileocolonic disease location (P < 0.05) in the stenosis-detectable group by IUS. The stenoses detected by IUS were significantly longer than those undetected by IUS (14.1 mm versus 5.2 mm, P < 0.05). CONCLUSIONS IUS delivered reliable results for clinically important small intestinal stenosis of CD with high diagnostic accuracy.
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Affiliation(s)
- Keiko Takeuchi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshihiro Inokuchi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masahiro Takahara
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masayasu Ohmori
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Eriko Yasutomi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shohei Oka
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shoko Igawa
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kensuke Takei
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuki Baba
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seiji Kawano
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasushi Yamasaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hideaki Kinugasa
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keita Harada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Sakiko Hiraoka
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Kawamura T, Yamamura T, Nakamura M, Maeda K, Sawada T, Ishikawa E, Iida T, Mizutani Y, Ishikawa T, Kakushima N, Furukawa K, Ohno E, Honda T, Kawashima H, Ishigami M. Accuracy of Serum Leucine-Rich Alpha-2 Glycoprotein in Evaluating Endoscopic Disease Activity in Crohn's Disease. Inflamm Bowel Dis 2023; 29:245-253. [PMID: 35436345 DOI: 10.1093/ibd/izac076] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Mucosal healing, confirmed by endoscopic evaluation, is the long-term goal of treatment for Crohn's disease (CD). Leucine-rich alpha-2 glycoprotein (LRG) is a new serum biomarker correlated with disease activity in inflammatory bowel disease. However, studies evaluating its relationship with CD, particularly in the context of small intestinal lesions, are scarce. The aim of this study was to investigate the accuracy of LRG in assessing endoscopic activity, especially remission, in patients with CD. METHODS Between July 2020 and March 2021, 72 patients with CD who underwent LRG testing and double-balloon endoscopy at the same time were included. Endoscopic activity was evaluated using the applied Simple Endoscopic Score for Crohn's disease, including small intestine lesions. The relationship of LRG with clinical symptoms and endoscopic activity was assessed, and its predictive accuracy was evaluated. RESULTS Leucine-rich alpha-2 glycoprotein showed a significant positive correlation with endoscopic activity (r = 0.619, P < .001), even in patients with active lesions in the small intestine (r = 0.626, P < .001). Multivariate logistic regression revealed that LRG was the only factor associated with endoscopic remission. An LRG cutoff value of 8.9 μg/mL had a sensitivity of 93.3%; specificity of 83.3%; positive predictive value of 96.6%; negative predictive value of 71.4%; accuracy of 91.7%; and area under the curve of 0.904 for the prediction of endoscopic remission. CONCLUSIONS Leucine-rich alpha-2 glycoprotein can be used in assessing endoscopic activity and is a reliable marker of endoscopic remission in CD patients. It can be an intermediate target in the treatment of CD.
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Affiliation(s)
- Tatsuya Kawamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Keiko Maeda
- Department of Endoscopy, Nagoya University Hospital, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
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11
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Serum Leucine-Rich α2 Glycoprotein: A Novel Biomarker for Transmural Inflammation in Crohn's Disease. Am J Gastroenterol 2022:00000434-990000000-00615. [PMID: 36571769 DOI: 10.14309/ajg.0000000000002127] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/14/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Leucine-rich alpha-2 glycoprotein (LRG) is a newly studied biomarker for inflammatory diseases. This study aimed to investigate whether LRG can be used for evaluating transmural activity in patients with Crohn's disease (CD). METHODS We performed magnetic resonance enterography (MRE) in 227 consecutive CD patients from June 2020 to August 2021. We prospectively compared MRE findings with clinical and laboratory data including LRG. MRE was evaluated using 2 validated scoring systems, and transmural inflammation was defined as having a maximum simplified magnetic resonance index of activity (sMaRIA) score of ≥4 and a 5-point classification score of ≥9, respectively. RESULTS The correlation between LRG and the total MRE score showed a positive correlation ( r = 0.576 for sMaRIA score, P < 0.01 and r = 0.633 for 5-point score, P < 0.01). Serum concentrations of LRG significantly increased as MRE scores increased ( P < 0.01). The area under the curve of LRG for sMaRIA score of ≥4 and 5-point score of ≥9 was 0.845 and 0.869, respectively, which was significantly higher than that of CDAI ( P < 0.01) or C-reactive protein ( P < 0.01). LRG levels of ≥14 μg/mL had a 67% sensitivity and a 90% specificity for sMaRIA score of ≥4, and 73% sensitivity and 89% specificity for 5-point score of ≥9. Patients with high LRG levels were also strongly associated with CD-related hospitalization, surgery, and clinical relapse compared to those with low LRG levels ( P < 0.01 for all). DISCUSSION LRG is a highly accurate serum biomarker for detecting transmural activity in CD patients. Results need to be validated in further multicenter studies.
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12
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Matsuoka K, Fujii T, Okamoto R, Yamada A, Kunisaki R, Matsuura M, Watanabe K, Shiga H, Takatsu N, Bamba S, Mikami Y, Yamamoto T, Shimoyama T, Motoya S, Torisu T, Kobayashi T, Ohmiya N, Saruta M, Matsuda K, Matsumoto T, Nakase H, Maemoto A, Shinzaki S, Murata Y, Yoshigoe S, Sasaki A, Yajima T, Hisamatsu T. Characteristics of adult patients newly diagnosed with Crohn's disease: interim analysis of the nation-wide inception cohort registry study of patients with Crohn's disease in Japan (iCREST-CD). J Gastroenterol 2022; 57:867-878. [PMID: 35930087 DOI: 10.1007/s00535-022-01907-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The Inception Cohort Registry Study of Patients with Crohn's Disease aimed to clarify clinical characteristics and disease course of newly diagnosed Crohn's disease patients in Japan throughout a 4-year period. Results from an interim analysis of the largest nation-wide registry study that covers approximately 1% of Crohn's disease patient population in Japan are reported. METHODS This prospective, observational registry study was conducted at 19 tertiary centers in Japan. Patients newly diagnosed with Crohn's disease after June 2016 (age ≥ 16 years at informed consent) were enrolled between December 17, 2018 and June 30, 2020. Patient demographics, diagnostic procedures and categories, disease location and lesion behavior (Montreal classification) at the time of diagnosis were recorded. RESULTS Of 673 patients enrolled, 672 (99.9%) were analyzed (458: men, 214: women), male-to-female ratio: 2.1, median age at diagnosis 25 (range 13-86) years; peak age of disease diagnosis: 20-24 years. Most common disease location was L3 (ileocolonic; 60.1%). Non-stricturing, non-penetrating (B1) disease was most common behavior (62.8%); 48.9% reported perianal lesions. Notably, age-wise analysis revealed disease phenotypes varied between patients aged < 40 and ≥ 40 years in terms of male-to-female ratio (2.5/1.3)/disease location (L3: 66.3%/37.0%)/disease behavior (B1: 66.4%/50.0%)/perianal lesion: (55.7%/20.5%) at Crohn's disease diagnosis, respectively. CONCLUSIONS Interim analysis of this nation-wide Inception Cohort Registry Study of Patients with Crohn's Disease revealed the demographics and disease characteristics of newly diagnosed Crohn's disease patients in Japan and demonstrated that disease phenotype varied between patients aged < 40 and ≥ 40 years, serving as important information for management of individual patients.
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Affiliation(s)
- Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Toshimitsu Fujii
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Ryuichi Okamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Akihiro Yamada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Minami-ku, Yokohama, Kanagawa, Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Kenji Watanabe
- Center for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hisashi Shiga
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Noritaka Takatsu
- Department of Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | - Shigeki Bamba
- Division of Digestive Endoscopy, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yohei Mikami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinjiku-ku, Tokyo, Japan
| | - Takayuki Yamamoto
- Department of Surgery and Inflammatory Bowel Disease Center, Yokkaichi Hazu Medical Center, Yokkaichi, Mie, Japan
| | - Takahiro Shimoyama
- Department of Surgery and Inflammatory Bowel Disease Center, Yokkaichi Hazu Medical Center, Yokkaichi, Mie, Japan
| | - Satoshi Motoya
- IBD Center, Hokkaido Preventive Welfare Federation of Agricultural Cooperative, Sapporo-Kosei General Hospital, Sapporo, Hokkaido, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
| | - Naoki Ohmiya
- Department of Advanced Endoscopy, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Koichiro Matsuda
- Department of Gastroenterology, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Iwate, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Atsuo Maemoto
- IBD Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Shinichiro Shinzaki
- Center for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan.,Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoko Murata
- Medical Affairs Division, Janssen Pharmaceutical K.K., Chiyoda-ku, Tokyo, Japan
| | - Shinichi Yoshigoe
- Medical Affairs Division, Janssen Pharmaceutical K.K., Chiyoda-ku, Tokyo, Japan
| | - Ayako Sasaki
- Medical Affairs Division, Janssen Pharmaceutical K.K., Chiyoda-ku, Tokyo, Japan
| | - Tsutomu Yajima
- Statistics & Decision Sciences, Janssen Pharmaceutical K.K., Chiyoda-ku, Tokyo, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan.
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13
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Han W, Wu J, Zhang P, Hu N, Mei Q, Hu J. Fecal calprotectin predicts endoscopic activity and mucosal healing of small bowel Crohn's disease evaluated by double-balloon endoscopy. Int J Colorectal Dis 2022; 37:1953-1961. [PMID: 35927341 DOI: 10.1007/s00384-022-04232-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Fecal calprotectin (FC) levels can reflect the level of intestinal inflammation. Crohn's disease (CD), which affects the small bowel, has not been linked to FC levels. We determined if FC levels and endoscopic activity were related by performing double-balloon endoscopy (DBE). METHODS Herein, patients with small bowel CD diagnosed by DBE between January 2020 and January 2022 were prospectively observed. Feces and blood samples of patients were collected before performing DBE and checked for the levels of FC and serological biomarkers. The endoscopic activity and mucosal healing (MH) were evaluated using the partial simple endoscopic score (pSES-CD). RESULTS In all 254 CD patients, FC levels were correlated with pSES-CD (r = 0.775, P < 0.001). Even in patients with isolated small bowel CD, FC levels were strongly correlated with pSES-CD (r = 0.753, P < 0.001). In all patients, FC as an endoscopic remission indicator was found to have an area under the curve (AUC) of 0.872, with a cut-off value of 156.09 µg/g. In patients with isolated small bowel CD, FC yielded a high AUC of 0.865 for predicting endoscopic remission, with a cut-off value of 211.48 µg/g, sensitivity of 73.95%, and specificity of 91.30%. FC was optimally cut-off at 76.99 µg/g to predict MH in accordance with the AUC of 0.877. CONCLUSIONS Using DBE findings, FC was found to be significantly correlated with pSES-CD. Even in isolated small bowel CD, FC may be a more reliable marker of accurately predicting endoscopic remission and MH.
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Affiliation(s)
- Wei Han
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Juan Wu
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Peipei Zhang
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Naizhong Hu
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Qiao Mei
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Jing Hu
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China.
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14
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Maconi G, Sorin V, Kopylov U, Barzilay O, Ferretti F, Innamorati S, Tonolini M, Eliakim R, Amitai MM. Diagnostic significance of mesenteric lymph node involvement in proximal small bowel Crohn's disease. Therap Adv Gastroenterol 2022; 15:17562848221118664. [PMID: 36035308 PMCID: PMC9403447 DOI: 10.1177/17562848221118664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/24/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Uri Kopylov
- Sackler Faculty of Medicine, Tel-Aviv
University, Tel-Aviv, Israel,Department of Gastroentergology, Chaim Sheba
Medical Center, Tel Hashomer, Israel
| | - Oranit Barzilay
- Sackler Faculty of Medicine, Tel-Aviv
University, Tel-Aviv, Israel,Department of Gastroentergology, Chaim Sheba
Medical Center, Tel Hashomer, Israel
| | - Francesca Ferretti
- Division of Gastroenterology, ASST
Fatebenefratelli-Sacco, L. Sacco University Hospital, Department of
Biochemical and Clinical Sciences, University of Milan, Milan, Italy
| | - Silvia Innamorati
- Department of Radiology, ASST
Fatebenefratelli-Sacco, L. Sacco University Hospital, Milan, Italy
| | - Massimo Tonolini
- Department of Radiology, ASST
Fatebenefratelli-Sacco, L. Sacco University Hospital, Milan, Italy
| | - Rami Eliakim
- Sackler Faculty of Medicine, Tel-Aviv
University, Tel-Aviv, Israel,Department of Gastroentergology, Chaim Sheba
Medical Center, Tel Hashomer, Israel
| | - Michal Marianne Amitai
- Department of Diagnostic Imaging, Chaim Sheba
Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel-Aviv
University, Tel-Aviv, Israel
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15
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Hibiya S, Ohtsuka K, Takenaka K, Kawamoto A, Matsuyama Y, Udagawa Y, Motobayashi M, Shimizu H, Fujii T, Saito E, Nagahori M, Okamoto R, Watanabe M. Mucosal healing of small intestinal stricture is associated with improved prognosis post-dilation in Crohn's disease. BMC Gastroenterol 2022; 22:218. [PMID: 35508963 PMCID: PMC9066722 DOI: 10.1186/s12876-022-02300-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Small intestinal stricture is a major cause for surgery in Crohn's disease (CD). Endoscopic balloon dilation (EBD) is performed for small intestinal strictures to avoid surgery, often repeatedly. However, factors that are associated with prognosis after EBD of small intestinal strictures remain poorly investigated. Mucosal healing is the therapeutic target in CD. We aimed to investigate the impact of mucosal healing defined by the presence of ulcers at the small intestinal stricture site on the prognosis of EBD in CD patients. METHODS We retrospectively included patients with CD who underwent initial EBD for endoscopically impassable small intestinal strictures from January 2012 to March 2020 at a single center. The association between presence of ulcer at the stricture site and surgery after EBD was examined by Cox proportional hazards model. RESULTS Of the 98 patients included, 63 (64.3%) had ulcer at the stricture site. 20 (31.7%) of these patients underwent surgery for the stricture in due course, whereas 4 (11.4%) of the patients without ulcer of the stricture underwent surgery. In multivariate analysis, patients with ulcer of the stricture had a significantly higher risk for surgery than those without ulcer (hazard ratio 4.84; 95% confidence interval 1.58-14.79). CONCLUSION Mucosal healing at the stricture site indicated a favorable prognosis after EBD for small intestinal strictures in CD.
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Affiliation(s)
- Shuji Hibiya
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
- Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Kazuo Ohtsuka
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
- Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan.
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
- Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Ami Kawamoto
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yusuke Matsuyama
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yumi Udagawa
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Maiko Motobayashi
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiromichi Shimizu
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshimitsu Fujii
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Eiko Saito
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ryuichi Okamoto
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Mamoru Watanabe
- TMDU Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
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16
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Kawamoto A, Takenaka K, Hibiya S, Ohtsuka K, Okamoto R, Watanabe M. Serum Leucine-Rich α 2 Glycoprotein: A Novel Biomarker For Small Bowel Mucosal Activity in Crohn's Disease. Clin Gastroenterol Hepatol 2022; 20:e1196-e1200. [PMID: 34216822 DOI: 10.1016/j.cgh.2021.06.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/08/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023]
Abstract
Active lesions in the small bowel (SB) have been independently associated with poorer prognoses in patients with Crohn's disease (CD)1; however, there has been a lack of accurate and convenient screening methods. Past studies have found that serum levels of the glycoprotein leucine-rich α2 glycoprotein (LRG) correlates with endoscopic activity in ulcerative colitis,2,3 and this is now available for routine clinical use as a biomarker in patients with inflammatory bowel disease in Japan. LRG has not yet been thoroughly verified in CD, and we investigated whether it can be used as a serum biomarker for detecting SB mucosal activity in patients with CD.
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Affiliation(s)
- Ami Kawamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan; Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Shuji Hibiya
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Ohtsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan; Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Ryuichi Okamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mamoru Watanabe
- TMDU Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan.
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17
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Takenaka K, Kawamoto A, Okamoto R, Watanabe M, Ohtsuka K. Artificial intelligence for endoscopy in inflammatory bowel disease. Intest Res 2022; 20:165-170. [PMID: 34986607 PMCID: PMC9081991 DOI: 10.5217/ir.2021.00079] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/25/2021] [Indexed: 12/09/2022] Open
Abstract
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.
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Affiliation(s)
- Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ami Kawamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryuichi Okamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mamoru Watanabe
- TMDU Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Ohtsuka
- Endoscopic Unit, Tokyo Medical and Dental University, Tokyo, Japan
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18
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Nakamura M, Kawashima H, Ishigami M, Fujishiro M. Indications and Limitations Associated with the Patency Capsule Prior to Capsule Endoscopy. Intern Med 2022; 61:5-13. [PMID: 34121000 PMCID: PMC8810252 DOI: 10.2169/internalmedicine.6823-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The retention of the capsule used during small bowel capsule endoscopy (SBCE) is a serious complication that can occur in patients with known or suspected small bowel stenosis, and a prior evaluation of the patency of the gastrointestinal (GI) tract is therefore essential. Patency capsule (PC) is a non-diagnostic capsule the same size as the diagnostic SBCE. To date, there are no clear guidelines regarding the contraindications for undergoing a PC evaluation prior to SBCE. Each small bowel disorder has specific occasions to inhibit the progress of PC and SBCE, even though they do not have any stenotic symptoms or abnormalities on imaging. In this review, we summarize the indications and limitations of PC prior to SBCE, especially the contraindications, and discuss clinical scenarios in which even PC should be avoided, and therefore such areas of stenosis should be evaluated by alternative modalities. We thus propose this new algorithm to evaluate the patency of the GI tract for patients with suspected and known small bowel stenosis in order that they may undergo SBCE safely.
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Affiliation(s)
- Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
| | | | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
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19
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Kishi M, Hirai F, Takatsu N, Hisabe T, Takada Y, Beppu T, Takeuchi K, Naganuma M, Ohtsuka K, Watanabe K, Matsumoto T, Esaki M, Koganei K, Sugita A, Hata K, Futami K, Ajioka Y, Tanabe H, Iwashita A, Shimizu H, Arai K, Suzuki Y, Hisamatsu T. A review on the current status and definitions of activity indices in inflammatory bowel disease: how to use indices for precise evaluation. J Gastroenterol 2022; 57:246-266. [PMID: 35235037 PMCID: PMC8938394 DOI: 10.1007/s00535-022-01862-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/06/2022] [Indexed: 02/04/2023]
Abstract
Many clinical trials have been conducted for inflammatory bowel disease (IBD), so various clinical indices (CIs) and endoscopic indices (EIs) have also been evaluated. However, recently, with the progress of IBD management, review of established indices from previous studies, and establishment of new indices, the landscape of the use of indices in clinical trials have changed. We investigated the number and frequency of the indices adapted in recent clinical trials for ulcerative colitis (CI and EI) and Crohn's disease (CI, EI, index related to magnetic resonance imaging, index for evaluating patient-reported outcomes, and health-related quality of life). Based on the results, we selected representative indices and further reviewed their content and characteristics. Moreover, various definitions, including clinical and endoscopic response or remission, have been described by means of representative indices in clinical trials.
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Affiliation(s)
- Masahiro Kishi
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Fumihito Hirai
- Department of Gastroenterology, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Jonan-ku, Fukuoka City, Fukuoka 814-0180 Japan
| | - Noritaka Takatsu
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Takashi Hisabe
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yasumichi Takada
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Tsuyoshi Beppu
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | | | - Makoto Naganuma
- The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Kazuo Ohtsuka
- Department of Endoscopy, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenji Watanabe
- Center for Inflammatory Bowel Disease, Division of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Medicine, Iwate Medical University, Iwate, Japan
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Kazutaka Koganei
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan
| | - Akira Sugita
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan
| | - Keisuke Hata
- Nihonbashi Muromachi Mitsui Tower Midtown Clinic, Tokyo, Japan
| | - Kitarou Futami
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yoichi Ajioka
- Division of Molecular and Diagnostic Pathology, Graduate School of Medicine and Dental Sciences, Niigata University, Niigata, Japan
| | - Hiroshi Tanabe
- Department of Pathology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Akinori Iwashita
- AII Research Institute of Pathology and Image Diagnosis, Fukuoka, Japan
| | - Hirotaka Shimizu
- Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Katsuhiro Arai
- Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | | | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
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20
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Yamanashi K, Katsurada T, Nishida M, Onishi R, Omotehara S, Otagiri S, Sakurai K, Nagashima K, Kinoshita K, Takagi R, Sakamoto N. Crohn's Disease Activity Evaluation by Transabdominal Ultrasonography: Correlation with Double-Balloon Endoscopy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2595-2605. [PMID: 33595133 DOI: 10.1002/jum.15645] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/30/2020] [Accepted: 01/10/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Transabdominal ultrasonography (US) has been reported as a useful tool for evaluating Crohn's disease (CD) activity. Endoscopic findings and Crohn's disease activity index (CDAI) are currently considered the gold standard for assessing CD activity. We assessed the correlation between US and double-balloon endoscopy (DBE), and CDAI for evaluating CD activity. METHODS We analyzed patients with CD undergoing US and DBE within 10 days between the procedures. The intestine was divided into four segments and analyzed by the US scoring system (US-CD) and the simple endoscopic score for Crohn's disease (SES-CD). CDAI was compared with US-CD and SES-CD. Spearman's rank correlation coefficient was used for statistical analysis. RESULTS Twenty-five patients with CD (11 women, 14 men; mean age 35.4 ± 14.9 years, range 16-65 years) were enrolled. Twenty-four patients received antitumor necrosis factor inhibitor therapy. CDAI was 128.1 (range 36-227). A significant moderate correlation was found between the US-CD and SES-CD in all segments (ρ = .64, P < .01). The US-CD showed a strong correlation with CDAI (ρ = .78, P < .01), whereas the SES-CD showed a moderate correlation (ρ = .55, P < .05). CONCLUSIONS US-CD and SES-CD showed a moderate correlation for assessing CD activity. US-CD showed a stronger correlation with CDAI than SES-CD, suggesting that US could more accurately evaluate the disease activity.
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Affiliation(s)
- Kana Yamanashi
- Department of Gastroenterology and Hepatology/Inflammatory Bowel Disease Group, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Takehiko Katsurada
- Department of Gastroenterology and Hepatology/Inflammatory Bowel Disease Group, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Mutsumi Nishida
- Division of Laboratory and Transfusion Medicine/Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan
| | - Reizo Onishi
- Department of Gastroenterology and Hepatology/Inflammatory Bowel Disease Group, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Satomi Omotehara
- Division of Laboratory and Transfusion Medicine/Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan
| | - Shinsuke Otagiri
- Department of Gastroenterology and Hepatology/Inflammatory Bowel Disease Group, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Kensuke Sakurai
- Department of Gastroenterology and Hepatology/Inflammatory Bowel Disease Group, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Kazunori Nagashima
- Department of Gastroenterology, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Kenji Kinoshita
- Department of Gastroenterology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Ryo Takagi
- Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Sapporo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology/Inflammatory Bowel Disease Group, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, Sapporo, Japan
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21
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Tao Y, Li H, Xu H, Tang W, Fan G, Yang X. Can the simplified magnetic resonance index of activity be used to evaluate the degree of activity in Crohn's disease? BMC Gastroenterol 2021; 21:409. [PMID: 34711180 PMCID: PMC8555259 DOI: 10.1186/s12876-021-01987-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 10/19/2021] [Indexed: 01/17/2023] Open
Abstract
Background and aims A simplified magnetic resonance index of activity (MaRIAs) was recently proposed. Our aim was to verify whether MaRIAs can accurately assess the activity degree of CD. Methods We retrospectively analyzed the MRI, ileocolonoscopy, fecal calprotectin (FC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) data of 93 CD patients. With the SES-CD as the gold standard, MaRIAs’ accuracy, the correlation of MaRIAs and SES-CD, FC, ESR, CRP, and interevaluator reliability were assessed. Results MaRIAs ≥ 1 detected segments with active CD with 90.80% specificity and 81.37% sensitivity (area under the curve was 0.91, 95% confidence interval 0.87–0.94). MaRIAs score of 2 or more detected severe lesions with 88.89% specificity and 95.12% sensitivity (AUC was 0.96, 95% confidence interval was 0.94–0.98). The MaRIAs score showed a high correlation with the SES-CD in the terminal ileum, transverse colon, right colon, and left colon (r = 0.85, 0.91, 0.88, 0.86, P < 0.001) and a moderate correlation with the SES-CD in the rectum (r = 0.74, P < 0.001). The global MaRIAs score was highly correlated with the global SES-CD (r = 0.90, P < 0.001). The global MaRIAs score was positively correlated with the fecal calprotectin (FC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) (r = 0.77, r = 0.64, and r = 0.68). The intragroup correlation coefficient (ICC) of the two physicians was nice in the terminal ileum, the right colon, the transverse colon, the left colon and was moderately good in the rectum. Conclusion MaRIAs can accurately evaluate the disease activity level of CD and are highly correlated with SES-CD and biomarkers. The interrater reliability of the two physicians was moderately good to nice.
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Affiliation(s)
- Yongli Tao
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jang Su, China
| | - Hong Li
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jang Su, China
| | - Han Xu
- Department of Gastroenterology, The Second Affiliated Hospital of Soochow University, Suzhou, Jang Su, China
| | - Wen Tang
- Department of Gastroenterology, The Second Affiliated Hospital of Soochow University, Suzhou, Jang Su, China
| | - Guohua Fan
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jang Su, China
| | - Xiaochun Yang
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jang Su, China.
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22
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Takenaka K, Kawamoto A, Hibiya S, Suzuki K, Fujii T, Motobayashi M, Shimizu H, Nagahori M, Saito E, Okamoto R, Watanabe M, Ohtsuka K. Higher concentrations of cytokine blockers are needed to obtain small bowel mucosal healing during maintenance therapy in Crohn's disease. Aliment Pharmacol Ther 2021; 54:1052-1060. [PMID: 34323301 DOI: 10.1111/apt.16551] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/07/2021] [Accepted: 07/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several studies have reported a positive correlation between serum drug concentrations and endoscopic remission in patients with Crohn's disease. AIM To examine the association between the concentrations of cytokine blockers (infliximab, adalimumab and ustekinumab) and endoscopic remission of small bowel lesions. METHOD This was a cross-sectional study conducted at a single tertiary referral centre. Patients with Crohn's disease who received maintenance cytokine blocker therapy were recruited from April 2018 to May 2020. We performed balloon-assisted enteroscopy and collected serum samples to measure drug concentrations. The primary endpoint was the relationship between the concentrations of cytokine blockers and endoscopic remission in the small bowel. RESULTS We enrolled 143 patients, 66, 44 and 33 of whom were receiving infliximab, adalimumab and ustekinumab, respectively. Enteroscopic findings showed that the rate of endoscopic remission of small bowel lesions was significantly lower than that of colonic lesions (P < 0.01). For each agent, the mean drug concentration in patients exhibiting endoscopic remission in the small bowel was higher than that observed in patients with endoscopic remission in the colon (but not in the small bowel) or with any active disease (either in the small bowel, colon or both). Patients with infliximab, adalimumab and ustekinumab concentrations >5, 14 and 4 µg/mL were nearly 5.3-, 9.4- and 14.7-times more likely to exhibit endoscopic remission of the small bowel, respectively. CONCLUSIONS Cytokine blocker treatment was less efficacious for small bowel inflammation than colonic inflammation. Higher serum concentrations were needed to achieve endoscopic remission of small bowel lesions.
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Affiliation(s)
- Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan.,Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Ami Kawamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shuji Hibiya
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan.,Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Kohei Suzuki
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan.,Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Toshimitsu Fujii
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Maiko Motobayashi
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiromichi Shimizu
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eiko Saito
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryuichi Okamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mamoru Watanabe
- TMDU Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Ohtsuka
- Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
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23
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Takenaka K, Kawamoto A, Ohtsuka K. Editorial: higher concentrations of cytokine blockers are needed to obtain small bowel mucosal healing during maintenance therapy in Crohn's disease-authors' reply. Aliment Pharmacol Ther 2021; 54:1087. [PMID: 34564889 DOI: 10.1111/apt.16579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan.,Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Ami Kawamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Ohtsuka
- Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
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24
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Takabayashi K, Hosoe N, Kato M, Hayashi Y, Miyanaga R, Nanki K, Fukuhara K, Mikami Y, Mizuno S, Sujino T, Mutaguchi M, Naganuma M, Yahagi N, Ogata H, Kanai T. Efficacy of Novel Ultrathin Single-Balloon Enteroscopy for Crohn's Disease: A Propensity Score-Matched Study. Gut Liver 2021; 14:619-625. [PMID: 31818049 PMCID: PMC7492490 DOI: 10.5009/gnl19228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/10/2019] [Accepted: 10/01/2019] [Indexed: 12/16/2022] Open
Abstract
Background/Aims The evaluation of small bowel lesions of Crohn's disease (CD) using balloon-assisted enteroscopy (BAE) is crucial because mucosal healing is associated with a good prognosis. However, BAE procedures are invasive, requiring sedation or analgesia to reduce the patient's pain. This study evaluated the clinical usefulness of a novel ultrathin single-balloon enteroscopy (SBE) procedure for CD. Methods This single-center retrospective study included 102 CD patients who underwent trans-anal SBE between January 2012 and May 2018. Of these patients, 82 underwent enteroscopy using conventional SBE, while 20 underwent ultrathin SBE. Patients were analyzed using propensity score matching, with 20 patients per group. The median duration of the examination, terminal ileum intubation rate, median cecum intubation time, median insertion depth, adverse events, and sedated dose in each group were compared. Results Before propensity score matching, the conventional SBE group had a larger number of surgical history patients than the ultrathin SBE group (p=0.05). After matching, the two groups did not significantly differ clinically. There were no significant differences in the mean duration of the examination, cecum intubation time, or terminal ileal intubation rate between ultrathin SBE and conventional SBE. The mean insertion depth of ultrathin SBE tended to be deeper than that of conventional SBE (p=0.09). The use of ultrathin SBE also reduced the sedative dose during needed for enteroscopy compared with conventional SBE (p=0.005). Conclusions Novel ultrathin SBE may be less painful for CD patients than conventional SBE.
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Affiliation(s)
- Kaoru Takabayashi
- Center for Diagnostic and Therapeutic Endoscopy, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Gastroenterology and Hepatology, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yukie Hayashi
- Center for Diagnostic and Therapeutic Endoscopy, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ryoichi Miyanaga
- Center for Diagnostic and Therapeutic Endoscopy, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kosaku Nanki
- Division of Gastroenterology and Hepatology, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kayoko Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Mikami
- Division of Gastroenterology and Hepatology, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinta Mizuno
- Division of Gastroenterology and Hepatology, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tomohisa Sujino
- Division of Gastroenterology and Hepatology, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Mutaguchi
- Center for Diagnostic and Therapeutic Endoscopy, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Cancer Center, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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25
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Pérez-Cuadrado Robles E, Pinho R, González-Suárez B, Mão-de-Ferro S, Chagas C, Esteban Delgado P, Carretero C, Figueiredo P, Rosa B, García-Lledó J, Nogales Ó, Ponte A, Andrade P, Juanmartiñena-Fernández JF, San-Juan-Acosta M, Lopes S, Prieto-Frías C, Egea Valenzuela J, Caballero N, Valdivieso-Cortázar E, Cardoso H, Gálvez C, Almeida N, Borque Barrera P, Gómez Rodríguez BJ, Sánchez Ceballos FL, Bernardes C, Alonso-Aguirre PA, Argüelles Arias F, Mascarenhas Saraiva M, Pérez-Cuadrado Martínez E. Small bowel enteroscopy - A joint clinical guideline by the Spanish and Portuguese small-bowel study groups. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 112:309-318. [PMID: 32188259 DOI: 10.17235/reed.2020.7020/2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small-bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication, and its diagnostic and therapeutic yield. A set of recommendations was issued accordingly.
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Affiliation(s)
| | - Rolando Pinho
- Gastroenterología, Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | | | - Susana Mão-de-Ferro
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa. E.P.E., Portugal
| | | | | | | | - Pedro Figueiredo
- Gastroenterology , Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Bruno Rosa
- Gastroenterology, Hospital Senhora da Oliveira, Portugal
| | | | - Óscar Nogales
- Aparato Digestivo, Hospital General Universitario Gregorio Marañón, España
| | - Ana Ponte
- Centro Hospitalar Vila Nova de GaiaEspinho, Portugal
| | | | | | | | - Sandra Lopes
- Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Portugal
| | | | | | - Noemí Caballero
- Gastrointestinal Endoscopy, Hospital Universitario Germans Trias i Pujol, Spain
| | | | | | - Consuelo Gálvez
- Gastroenterología, Hospital Clínico Universitario de Valencia, Spain
| | - Nuno Almeida
- Gastroenterology , Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Pilar Borque Barrera
- Aparato Digestivo. Unidad de Endoscopia, Hospital Universitario Nuestra Sra. de Candelaria, España
| | | | | | - Carlos Bernardes
- Gastroenterology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Portugal
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26
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Yamada K, Nakamura M, Yamamura T, Maeda K, Sawada T, Mizutani Y, Ishikawa E, Ishikawa T, Kakushima N, Furukawa K, Ohno E, Kawashima H, Honda T, Ishigami M, Fujishiro M. Diagnostic yield of colon capsule endoscopy for Crohn's disease lesions in the whole gastrointestinal tract. BMC Gastroenterol 2021; 21:75. [PMID: 33593297 PMCID: PMC7888071 DOI: 10.1186/s12876-021-01657-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn's disease (CD) can involve the upper gastrointestinal (GI) tract as well as the small and large bowel. PillCam colon capsule endoscopy (PCCE-2) enables observation of the whole GI tract, but its diagnostic yield for CD lesions in the whole GI tract remains unknown. AIM To elucidate the diagnostic yield of PCCE-2 in patients with CD. METHODS Patients with CD who underwent PCCE-2 and double-balloon endoscopy (DBE) using oral and anal approaches were evaluated for CD lesions in the whole GI tract. We divided the small bowel into three segments (jejunum, ileum, and terminal ileum), and the large bowel into four segments (right colon, transverse colon, left colon, rectum). Detection of ulcer scars, erosion, ulcers, bamboo joint-like appearance, and notch-like appearance was assessed in each segment. The diagnostic yield of PCCE-2 was analyzed based on the DBE results as the gold standard. RESULTS Of the total 124 segments, the sensitivities of PCCE-2 for ulcer scars, erosion, and ulcers were 83.3%, 93.8%, and 88.5%, respectively, and the specificities were 76.0%, 78.3%, and 81.6%, respectively. For the 60 small bowel segments, the sensitivities were 84.2%, 95.5%, and 90.0%, respectively, and the specificities were 63.4%, 86.8%, and 87.5%, respectively. For the 64 large bowel segments, the sensitivities were 80.0%, 90.0%, and 83.3%, respectively, and the specificities were 84.7%, 72.2%, and 77.6%, respectively. CONCLUSION PCCE-2 provides a high diagnostic yield for lesions in the whole GI tract of patients with CD. Thus, we recommend its use as a pan-enteric tool in clinical settings.
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Affiliation(s)
- Keisaku Yamada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan.
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Keiko Maeda
- Department of Endoscopy, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, Japan
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MRE Evaluation of Intestinal Inflammation: Qualitative and Quantitative Assessment. Top Magn Reson Imaging 2021; 30:13-22. [PMID: 33528208 DOI: 10.1097/rmr.0000000000000270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
ABSTRACT Magnetic resonance enterography (MRE) is a powerful tool for evaluation and management of patients with Crohn disease. Changes of active inflammation of the small bowel can reliably and reproducibly be detected and monitored. Findings indicative of active inflammation include bowel wall thickening, intramural edema and mural hyperenhancement. These changes are most commonly reported qualitatively; however, quantitative indices have also been developed and validated to measure and monitor inflammation both for clinical care and research purposes. This article describes the essential findings of active inflammation on MRE as well as the fundamentals of both qualitative and quantitative assessment and reporting.
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Nakase H, Uchino M, Shinzaki S, Matsuura M, Matsuoka K, Kobayashi T, Saruta M, Hirai F, Hata K, Hiraoka S, Esaki M, Sugimoto K, Fuji T, Watanabe K, Nakamura S, Inoue N, Itoh T, Naganuma M, Hisamatsu T, Watanabe M, Miwa H, Enomoto N, Shimosegawa T, Koike K. Evidence-based clinical practice guidelines for inflammatory bowel disease 2020. J Gastroenterol 2021; 56:489-526. [PMID: 33885977 PMCID: PMC8137635 DOI: 10.1007/s00535-021-01784-1] [Citation(s) in RCA: 195] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease (IBD) is a general term for chronic or remitting/relapsing inflammatory diseases of the intestinal tract and generally refers to ulcerative colitis (UC) and Crohn's disease (CD). Since 1950, the number of patients with IBD in Japan has been increasing. The etiology of IBD remains unclear; however, recent research data indicate that the pathophysiology of IBD involves abnormalities in disease susceptibility genes, environmental factors and intestinal bacteria. The elucidation of the mechanism of IBD has facilitated therapeutic development. UC and CD display heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management depends on the understanding and tailoring of evidence-based interventions by physicians. In 2020, seventeen IBD experts of the Japanese Society of Gastroenterology revised the previous guidelines for IBD management published in 2016. This English version was produced and modified based on the existing updated guidelines in Japanese. The Clinical Questions (CQs) of the previous guidelines were completely revised and categorized as follows: Background Questions (BQs), CQs, and Future Research Questions (FRQs). The guideline was composed of a total of 69 questions: 39 BQs, 15 CQs, and 15 FRQs. The overall quality of the evidence for each CQ was determined by assessing it with reference to the Grading of Recommendations Assessment, Development and Evaluation approach, and the strength of the recommendation was determined by the Delphi consensus process. Comprehensive up-to-date guidance for on-site physicians is provided regarding indications for proceeding with the diagnosis and treatment.
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Affiliation(s)
- Hiroshi Nakase
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan ,grid.263171.00000 0001 0691 0855Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, S-1, W-16, Chuoku, Sapporo, Hokkaido 060-8543 Japan
| | - Motoi Uchino
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Shinichiro Shinzaki
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Minoru Matsuura
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Katsuyoshi Matsuoka
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Taku Kobayashi
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Masayuki Saruta
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Fumihito Hirai
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Keisuke Hata
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Sakiko Hiraoka
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Motohiro Esaki
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Ken Sugimoto
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Toshimitsu Fuji
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Kenji Watanabe
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Shiro Nakamura
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Nagamu Inoue
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Toshiyuki Itoh
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Makoto Naganuma
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Tadakazu Hisamatsu
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Mamoru Watanabe
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Hiroto Miwa
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Nobuyuki Enomoto
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Tooru Shimosegawa
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Kazuhiko Koike
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
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Pan J, Fu D, Li Y, Wang Y, Lian G, Liu X. Body weight, serum albumin and food intolerance were linked to upper gastrointestinal Crohn's disease: a 7-year retrospective analysis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1370. [PMID: 33313115 PMCID: PMC7723648 DOI: 10.21037/atm-20-2212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The clinical features of upper gastrointestinal (L4) Crohn’s disease (CD) and its subtypes, along with the associated and nutritional status, remain poorly described. Our aim was to evaluate the clinical characteristics of L4 CD phenotype and its subtypes at diagnosis, and their relationship with the nutritional status. Methods A retrospective study was conducted on 869 CD patients diagnosed between 2013 and 2019, and the association between the clinical characteristics and nutritional status of L4 patients was determined using Random forest importance ranking and logistic regression. Results The majority of the patients (59.72%) presented L4 lesions, of which 335, 158 and 26 had proximal ileal, jejunal and esophago-gastroduodenal (EGD) lesions respectively. L4 patients were predominantly male (OR 2.07), smoker (OR 1.80), and had higher body weight and BMI, longer disease course, and stricturing disease (OR 1.88). Furthermore, the serum albumin level, body weight and disease course showed higher MDG in the random forest importance ranking test for L4 CD and L4-proximal ileal types. According to logistic regression, body weight (OR 1.054), disease course (OR 1.010), stricturing behavior (OR 4.998) and tomato intolerance (OR 1.313) were the independent risk factors for L4. In addition, body weight (OR 1.042) and stricturing behavior (OR 3.152) were the relevant factors for proximal ileal subtype, and stricturing behavior (OR 4.206) and perianal disease (OR 0.339) for jejunal subtype. Conclusions L4 disease has a higher incidence rate compared to the non-L4 CD, and mainly affects males, and those with prolonged disease course, stricturing behavior, higher weight, BMI, albumin levels and food intolerance (FI).
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Affiliation(s)
- Jianfeng Pan
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
| | - Dongni Fu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
| | - Yong Li
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
| | - Yifan Wang
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
| | - Guanghui Lian
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaowei Liu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
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Watanabe K. Clinical management for small bowel of Crohn's disease in the treat-to-target era: now is the time to optimize treatment based on the dominant lesion. Intest Res 2020; 18:347-354. [PMID: 33131231 PMCID: PMC7609393 DOI: 10.5217/ir.2020.00032] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023] Open
Abstract
A treat-to-target strategy, in which treatment is continuously adjusted according to the results of scheduled objective monitoring, is optimal for patients with Crohn's disease (CD) in the era of biologics. The small bowel is a common site of intractable CD, which may result from multiple strictures or expanding lesions. To improve the prognosis of patients with small bowel CD, lesions should be proactively monitored within the subclinical phase. Objective assessment of small bowel lesions is technically difficult, however, due to the relatively poor correlation between endoscopic activity and clinical symptoms or biomarker titers. The presence of proximal small bowel lesions and asymptomatic "Real Silent CD" must be considered. Endoscopy remains the gold standard to assess these lesions. In clinical practice, the advantages and disadvantages of each imaging modality and biomarker must be carefully weighed for appropriate application and reliable monitoring. The prevalence of small bowel lesions depends on the precision of the imaging modality used for detection. Clinical management should be based on the dominant location of the intestinal lesions rather than classical classification. Optimal strategies for detecting and treating small bowel lesions in patients with CD must be developed utilizing reliable, precise, and objective monitoring.
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Affiliation(s)
- Kenji Watanabe
- Center for Inflammatory Bowel Disease, Division of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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Takenaka K, Fujii T, Suzuki K, Shimizu H, Motobayashi M, Hibiya S, Saito E, Nagahori M, Watanabe M, Ohtsuka K. Small Bowel Healing Detected by Endoscopy in Patients With Crohn's Disease After Treatment With Antibodies Against Tumor Necrosis Factor. Clin Gastroenterol Hepatol 2020; 18:1545-1552. [PMID: 31442600 DOI: 10.1016/j.cgh.2019.08.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/29/2019] [Accepted: 08/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is important to objectively assess Crohn's disease (CD) activity in patients treated with antibodies against tumor necrosis factor (anti-TNF). Detection of healing by endoscopy (endoscopic healing) associates with patient outcome, based on evidence from studies of ileocolonoscopy. We assessed endoscopic healing after treatment, based on findings from balloon-assisted enteroscopy (BAE), in patients with CD. METHODS We performed a post-hoc analysis of data from a clinical trial from 116 patients with CD (46 with ileal and 70 with ileocolonic type) who received induction and then maintenance therapy with anti-TNF agents from January 2013 through March 2018 at a single center in Japan. We compared findings from BAE before induction therapy and then again during maintenance therapy (median 13 months later). Endoscopic healing was defined as the modified simple endoscopic score for CD below 5. We also collected data on previous treatments, makers of inflammation, and disease type. RESULTS Before treatment, small bowel ulcerations were present in 114 patients (98%); 42 patients (60%) with ileocolonic disease had colon ulcerations. During maintenance therapy, 41/114 patients (36%) had small bowel endoscopic healing; all the patients with small bowel endoscopic healing also had colonic endoscopic healing. Colonic endoscopic healing was observed in 33/42 patients (79%). The proportion of patients with small bowel endoscopic healing was significantly lower than that of colonic endoscopic healing (P < .001). Among all patients, failure to achieve small bowel endoscopic healing was significantly associated with structuring or penetrating disease (P = .014), lack of concomitant treatment with immunomodulators (P = .015), and having received previous treatment with an anti-TNF agents (P = .018). CONCLUSIONS In a post-hoc analysis of patients with CD treated with anti-TNF agents, we found small bowel ulcerations, detected by BAE, to be more difficult to heal than colon ulcerations.
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Affiliation(s)
- Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan; Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Toshimitsu Fujii
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohei Suzuki
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan; Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Hiromichi Shimizu
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Maiko Motobayashi
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shuji Hibiya
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eiko Saito
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Ohtsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan; Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan.
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Dulai PS, Jairath V. How Do We Treat Inflammatory Bowel Diseases to Aim For Endoscopic Remission? Clin Gastroenterol Hepatol 2020; 18:1300-1308. [PMID: 31887449 DOI: 10.1016/j.cgh.2019.12.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/29/2019] [Accepted: 12/06/2019] [Indexed: 02/06/2023]
Abstract
Crohn's disease and ulcerative colitis are heterogeneous conditions which may manifest with 1 or more of a constellation of abnormal symptoms, elevated biomarkers, and/or objective evidence of inflammation on endoscopic or cross-sectional evaluation. Whilst resolution of symptoms and restoration of quality of life is the primary goal for patients following a disease flare, there may be discordance between resolution of symptoms, biomarkers, and endoscopy. Increased emphasis is placed on the achievement of endoscopic remission, given it is associated with improved outcomes and reduction in hospitalization and surgeries. As the therapeutic armamentarium for inflammatory bowel disease does not achieve remission in all patients, there is greater emphasis on repetitive interval-based assessment of disease activity with sequential algorithmic treatment adjustments until endoscopic remission is achieved, in a so-called treat-to-target approach. We review the role of symptoms, biomarkers, imaging and endoscopy within treat-to-target algorithms and provide a practical guidance to their use in clinical practice.
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Affiliation(s)
- Parambir S Dulai
- Division of Gastroenterology, University of California San Diego, San Diego, California.
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Magnetic Resonance Enterography and Capsule Endoscopy in Patients Undergoing Patency Capsule for the Evaluation of Small Bowel Crohn's Disease: A Korean Clinical Experience. Gastroenterol Res Pract 2020; 2020:8129525. [PMID: 32328099 PMCID: PMC7160711 DOI: 10.1155/2020/8129525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/24/2020] [Accepted: 02/28/2020] [Indexed: 12/21/2022] Open
Abstract
Objective Studies comparing magnetic resonance enterography (MRE) and capsule endoscopy (CE) for the assessment of small bowel (SB) Crohn's disease (CD) are scarce in Korea. In addition, there is no Korean experience of patency capsule (PC) examination prior to CE. The primary aim of this study was to compare diagnostic yields of MRE and CE for the assessment of SB CD. Secondary objectives were to compare the detection rate of proximal SB lesions by each modality in the Montreal classification and evaluate the safety and feasibility of PC in Korean CD patients. Methods MRE was performed as the first examination to assess SB CD. PC examination and CE were then performed. Diagnostic yields of active SB disease by MRE and CE were then analyzed. Results Disintegration of the patency capsule was shown in 5 patients out of 26 patients, who did not undergo CE. These 5 patients were accounted as negative CE findings. Overall, MRE and CE detected 80.8% and 65.4% of active SB lesions of CD in 26 patients, respectively (P = 0.212). MRE and CE detected 0% (0/26) and 19.2% (5/26) (P = 0.051) of jejunal lesions, 30.8% (8/26) and 42.3% (11/26) (P = 0.388) of proximal ileal lesions, and 80.8% (21/26) and 53.8% (14/26) (P = 0.039) of terminal ileal lesions, respectively. According to the Montreal classification, MRE and CE independently detected proximal disease (L4) in 30.8% (8/26) and 53.8% (14/26) (P = 0.092), respectively. Conclusions The diagnostic yields of MRE and CE for the assessment of SB CD including proximal SB lesions were similar. MRE is a more objective tool for detecting clinically relevant stricture than PC although PC examination could be performed safely before CE to prove the patency of SB. This trial is registered with KCT0004305.
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Pérez-Cuadrado-Robles E, Pinho R, Gonzalez B, Mão de Ferro S, Chagas C, Esteban Delgado P, Carretero C, Figueiredo P, Rosa B, García Lledó J, Nogales Ó, Ponte A, Andrade P, Juanmartiñena-Fernández JF, San-Juan-Acosta M, Lopes S, Prieto-Frías C, Egea-Valenzuela J, Caballero N, Valdivieso-Cortazar E, Cardoso H, Gálvez C, Almeida N, Borque Barrera P, Gómez-Rodríguez BJ, Sánchez Ceballos F, Bernardes C, Alonso P, Argüelles-Arias F, Mascarenhas Saraiva M, Pérez-Cuadrado-Martínez E. Small Bowel Enteroscopy - A Joint Clinical Guideline from the Spanish and Portuguese Small Bowel Study Groups. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:324-335. [PMID: 32999905 DOI: 10.1159/000507375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/19/2020] [Indexed: 12/13/2022]
Abstract
The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication and on its diagnostic and therapeutic yields. A set of recommendations were issued accordingly.
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Affiliation(s)
| | - Rolando Pinho
- Department of Gastroenterology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal
| | - Begoña Gonzalez
- Department of Gastroenterology. Endoscopy Unit, ICMDiM, Hospital Clínic, Barcelona, Spain
| | - Susana Mão de Ferro
- Department of Gastroenterology, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisbon, Portugal
| | - Cristina Chagas
- Department of Gastroenterology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | | | - Cristina Carretero
- Department of Gastroenterology, University of Navarra Clinic, Pamplona, Spain
| | - Pedro Figueiredo
- Gastroenterology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Bruno Rosa
- Department of Gastroenterology, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute, School of Medicine, University of Minho, ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Javier García Lledó
- Department of Gastroenterology, Endoscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Óscar Nogales
- Department of Gastroenterology, Endoscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Ponte
- Department of Gastroenterology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal
| | - Patrícia Andrade
- Department of Gastroenterology, Centro Hospitalar São João, Porto, Portugal
| | | | - Mileidis San-Juan-Acosta
- Department of Gastroenterology, Gastrointestinal Endoscopy Unit, Hospital Universitario Nuestra Señora de Candelaria, Candelaria, Tenerife, Spain
| | - Sandra Lopes
- Gastroenterology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - César Prieto-Frías
- Department of Gastroenterology, University of Navarra Clinic, Pamplona, Spain
| | - Juan Egea-Valenzuela
- Unit of Gastrointestinal Endoscopy, Department of Digestive Disease, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Noemí Caballero
- Department of Gastrointestinal Endoscopy, Hospital Universitario Germans Trias i Pujol, Badalona, Spain
| | | | - Hélder Cardoso
- Department of Gastroenterology, Centro Hospitalar São João, Porto, Portugal
| | - Consuelo Gálvez
- Department of Gastroenterology. Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Nuno Almeida
- Gastroenterology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Pilar Borque Barrera
- Department of Gastroenterology, Gastrointestinal Endoscopy Unit, Hospital Universitario Nuestra Señora de Candelaria, Candelaria, Tenerife, Spain
| | - Blas José Gómez-Rodríguez
- Department of Gastroenterology, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
| | | | - Carlos Bernardes
- Department of Gastroenterology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Pedro Alonso
- Department of Gastroenterology, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Federico Argüelles-Arias
- Department of Gastroenterology, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
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Yoo JH, Holubar S, Rieder F. Fibrostenotic strictures in Crohn's disease. Intest Res 2020; 18:379-401. [PMID: 32259917 PMCID: PMC7609387 DOI: 10.5217/ir.2019.09148] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 01/26/2020] [Indexed: 12/15/2022] Open
Abstract
The use of biologic agents including anti-tumor necrosis factor monoclonal antibodies followed by anti-integrins and anti-interleukins has drastically changed the treatment paradigm of Crohn’s disease (CD) by improving clinical symptoms and mucosal healing. However, up to 70% of CD patients still eventually undergo surgery mainly due to fibrostenotic strictures. There are no specific anti-fibrotic drugs yet. This review comprehensively addresses the mechanism, prediction, diagnosis and treatment of the fibrostenotic strictures in CD. We also introduce promising anti-fibrotic agents which may be available in the near future and summarize challenges in developing novel therapies to treat fibrostenotic strictures in CD.
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Affiliation(s)
- Jun Hwan Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Stefan Holubar
- Department of Colorectal Surgery, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Morita Y, Bamba S, Inatomi O, Takahashi K, Imai T, Murata M, Ohno M, Sasaki M, Tsujikawa T, Andoh A. Prototype single-balloon enteroscopy with passive bending and high force transmission improves depth of insertion in the small intestine. Intest Res 2020; 18:229-237. [PMID: 32252502 PMCID: PMC7206344 DOI: 10.5217/ir.2019.09150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background/Aims We retrospectively analyzed Crohn’s disease (CD) patients with small intestinal strictures who underwent single-balloon enteroscopy (SBE) to ascertain whether prototype SBEs with a passive bending mechanism and high force transmission insertion tube had better insertability in the small intestine than a conventional SBE. Methods Among 253 CD patients who underwent SBE, we identified 94 CD patients who had undergone attempted endoscopic balloon dilatation (EBD) for small intestinal stenosis for inclusion in this study. We analyzed whether the type of scope used for their initial procedure affected the cumulative surgery-free rate. For the insertability analysis, patients who underwent SBE at least twice were divided into 3 groups according to the type of scope used: conventional SBE only, prototype SBE only, and both conventional and prototype SBEs. For each group, depth of insertion, procedure time, and number of EBDs were compared in the same patient at different time points. Results The success rate of EBD was 88.3%. The 5- and 10-year cumulative surgery-free rate was 75.7% and 72.8%, respectively. Cox regression analysis indicated that the factors contributing to surgery were long stricture (≥2 cm), EBD failure, and elevated Crohn’s Disease Activity Index, but not the type of scope used for EBD. The prototype SBEs significantly improved the depth of insertion (P=0.03, Wilcoxon’s signed-rank test). Conclusions In CD patients with small intestinal stenosis, the prototype SBEs with a passive bending mechanism and high force transmission insertion tube did not improve long-term EBD outcome but did improve deep insertability. (Clinical Trial Registration No. UMIN000037102)
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Affiliation(s)
- Yasuhiro Morita
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Shigeki Bamba
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Osamu Inatomi
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | | | - Takayuki Imai
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Masaki Murata
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Masashi Ohno
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Masaya Sasaki
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Tomoyuki Tsujikawa
- Department of Comprehensive Internal Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
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Abstract
BACKGROUND Crohn's disease (CD) is a chronic and destructive bowel disease; continued disease activity can lead to penetrating complications. With the recent advent of effective medications, the importance of using a treat-to-target approach to guide therapy is becoming important. METHODS In this review, we reviewed the previous evidence for evaluating CD lesions. RESULTS We describe ileocolonoscopy's role in assessing disease activity, as well as recent progress in modalities, such as balloon-assisted endoscopy, capsule endoscopy, magnetic resonance enterography, computed tomography enterography, and ultrasonography. Advances in modalities have changed CD assessment, with small-bowel involvement becoming more important. CONCLUSIONS Proper optimization is necessary in clinical practice.
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38
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1251] [Impact Index Per Article: 250.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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40
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Pennazio M, Venezia L, Cortegoso Valdivia P, Rondonotti E. Device-assisted enteroscopy: An update on techniques, clinical indications and safety. Dig Liver Dis 2019; 51:934-943. [PMID: 31138509 DOI: 10.1016/j.dld.2019.04.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/22/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022]
Abstract
After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.
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Affiliation(s)
- Marco Pennazio
- University Division of Gastroenterology, Department of Medical Sciences, University of Turin, City of Health and Science, Italy.
| | - Ludovica Venezia
- University Division of Gastroenterology, Department of Medical Sciences, University of Turin, City of Health and Science, Italy
| | - Pablo Cortegoso Valdivia
- University Division of Gastroenterology, Department of Medical Sciences, University of Turin, City of Health and Science, Italy
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Abstract
PURPOSE OF REVIEW The review discusses the roles of small bowel capsule endoscopy and deep enteroscopy in patients with Crohn's disease. It highlights recent advances in the field and identifies areas where evidence is lacking. RECENT FINDINGS Small bowel capsule endoscopy has an important role in the follow-up of patients with Crohn's disease after escalation of therapy and in the postoperative assessment period following surgical resection. Device-assisted enteroscopy offers the therapeutic advantage of small bowel dilatation, which may result in a reduction in the number of surgical resections required, thus avoiding long-term complications, such as short bowel syndrome and malabsorption. SUMMARY Capsule endoscopy has an established role in the diagnosis and management of small bowel Crohn's disease. It is used in the setting of suspected Crohn's disease when ileocolonoscopy is negative and for the assessment of extent of small bowel disease in established Crohn's disease. It is relatively well tolerated because of the provision of patency capsule endoscopy to minimize the risk of inadvertent capsule retention. Device-assisted enteroscopy aids with the diagnosis of Crohn's disease as it enables histology to be taken from inflamed areas within the small bowel. Therapeutic procedures can be carried out during device-assisted enteroscopy including dilatation of Crohn's disease-related strictures and retrieval of retained capsules.
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42
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Maehata Y, Nagata Y, Moriyama T, Matsuno Y, Hirano A, Umeno J, Torisu T, Manabe T, Kitazono T, Esaki M. Risk of surgery in patients with stricturing type of Crohn's disease at the initial diagnosis: a single center experience. Intest Res 2019; 17:357-364. [PMID: 30781932 PMCID: PMC6667375 DOI: 10.5217/ir.2018.00107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 01/23/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS It remains uncertain which patients with stricturing-type Crohn's disease (CD) require early small bowel surgery after the initial diagnosis. We aimed to clarify clinical characteristics associated with the intervention in such condition of CD. METHODS We retrospectively evaluated the clinical course of 53 patients with CD and small bowel strictures who were initially treated with medications after the initial diagnosis. We investigated possible associations between small bowel surgery and the following: clinical factors and radiologic findings at initial diagnosis and the types of medications administered during follow-up. RESULTS Twenty-eight patients (53%) required small bowel resection during a median follow-up period of 5.0 years (range, 0.5-14.3 years). The cumulative incidence rates of small bowel surgery at 2, 5, and 10 years were 26.4%, 41.0%, and 63.2%, respectively. Univariate analysis indicated that obstructive symptoms (P=0.036), long-segment stricture (P<0.0001), and prestenotic dilation (P<0.0001) on radiography were associated with small bowel surgery, and immunomodulatory (P=0.037) and biological therapy (P=0.008) were significant factors during follow-up. Multivariate analysis revealed that long-segment stricture (hazard ratio [HR], 4.25; 95% confidence interval [CI], 1.78-10.53; P=0.001) and prestenotic dilation (HR, 3.41; 95% CI, 1.24-9.62; P=0.018) on radiography showed a positive correlation with small bowel surgery, and biological therapy (HR, 0.40; 95% CI, 0.15-0.99; P=0.048) showed a negative correlation. CONCLUSIONS CD patients with long-segment stricture and prestenotic dilation on radiography seem to be at a higher risk of needing small bowel surgery. For such patients, early surgical intervention might be appropriate, even at initial diagnosis.
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Affiliation(s)
- Yuji Maehata
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Maehata Clinic, Kagoshima, Japan
| | - Yutaka Nagata
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomohiko Moriyama
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuichi Matsuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Atsushi Hirano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Junji Umeno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tatsuya Manabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Motohiro Esaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Endoscopic Diagnostics and Therapeutics, Saga University Hospital, Saga, Japan
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Sagami S, Kobayashi T, Kikkawa N, Umeda S, Nakano M, Toyonaga T, Okabayashi S, Ozaki R, Hibi T. Combination of colonoscopy and magnetic resonance enterography is more useful for clinical decision making than colonoscopy alone in patients with complicated Crohn's disease. PLoS One 2019; 14:e0212404. [PMID: 30785943 PMCID: PMC6382266 DOI: 10.1371/journal.pone.0212404] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/25/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS The small bowel is affected in more than half of patients with Crohn's disease (CD) at the time of diagnosis, and small bowel involvement has a negative impact on the long-term outcome. Many patients reportedly have active lesions in the small intestine even in patients in clinical remission. This study was performed to compare findings of magnetic resonance enterography (MRE) and ileocolonoscopy. METHODS A single-center retrospective study was conducted in 50 patients (60 imaging series) with CD, for whom MRE was additionally performed during the bowel preparation for subsequent ileocolonoscopy. Endoscopic remission was defined as a Simple Endoscopic Score for CD (SES-CD) of <5. MRE remission was defined as a Magnetic Resonance Index of Activity (MaRIA) score of <50. The time to treatment escalation was assessed by the log-rank test. RESULTS Importantly, 7 of 29 patients (24.1%) with endoscopic remission had a MaRIA score of ≥50. Both SES-CD and MaRIA correlated with the need for treatment escalation (P = 0.025, P = 0.009, respectively). MRE predicted the need for treatment escalation even in patients with endoscopic remission. Although no correlation was present between SES-CD and MaRIA score in patients with structuring/penetrating disease, or insufficient ileal insertion (<10cm), a high MaRIA score still correlated with the need for treatment escalation in stricturing or penetrating disease (P = 0.0306). CONCLUSIONS The MaRIA score predicts the need for treatment escalation even in patients with endoscopic remission, indicating that addition of MRE to conventional ileocolonoscopy alone can be a useful, noninvasive tool for monitoring CD especially in stricturing or penetrating disease.
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Affiliation(s)
- Shintaro Sagami
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
- * E-mail:
| | - Nao Kikkawa
- Department of Radiology, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
| | - Satoko Umeda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Masaru Nakano
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
| | - Takahiko Toyonaga
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
| | - Shinji Okabayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
| | - Ryo Ozaki
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Tokyo, Japan
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Dalzell AM, Ba'Ath ME. Paediatric inflammatory bowel disease: review with a focus on practice in low- to middle-income countries. Paediatr Int Child Health 2019; 39:48-58. [PMID: 30900526 DOI: 10.1080/20469047.2019.1575056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Inflammatory bowel disease (IBD) should be considered in any child with a persistently altered bowel habit. Growth failure may be a consequence and there may also be extra-intestinal manifestations. Oesophago-gastroduodenoscopy and colonoscopy and conventional histopathology are the diagnostic tools of choice in IBD. The identification and management of children with IBD in resource-poor settings is difficult and there are few data on its prevalence in low- and middle-income countries. The main challenges are a lack of resources and infrastructure including trained personnel in settings where there are other priorities for maintaining the health and wellbeing of children. The identification and management of children with inflammatory bowel conditions often depends on the enthusiasm, skill and commitment of a few dedicated individuals. Abbreviations: ADA: Adalimumab; CD: Crohn disease; ECCO: European Crohn's and Colitis Organisation; EEN: exclusive enteral nutrition; ESPGHAN: European Society for Paediatric Gastroenterology Hepatology and Nutrition; FMT: faecal microbiota transplantation; GDP: gross domestic product; HIC: high-income countries; IBD: inflammatory bowel disease; IBDU: inflammatory bowel disease unclassified; IC: ileocolonoscopy; IFX: infliximab; IPAA: ileal pouch anal anastomosis; LMIC: low- and middle-income countries; MH: mucosal healing; OGD: oesophago-gastroduodenoscopy; PCDAI: Paediatric Crohn's Disease Activity Index; PIBD: paediatric inflammatory bowel disease; PUCAI: Paediatric Ulcerative Colitis Activity Index; UC: ulcerative colitis; UGIT: upper gastrointestinal tract; VEO-IBD: very early-onset IBD; WLE: white light endoscopy; 5-ASA: 5 aminosalicylic acid; 6-MP: 6-mercaptopurine.
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45
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Crohn Disease: A 5-Point MR Enterocolonography Classification Using Enteroscopic Findings. AJR Am J Roentgenol 2019; 212:67-76. [DOI: 10.2214/ajr.17.18897] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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46
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Iwamoto F, Matsuoka K, Motobayashi M, Takenaka K, Kuno T, Tanaka K, Tsukui Y, Kobayashi S, Yoshida T, Fujii T, Saito E, Yamaguchi T, Nagahori M, Sato T, Ohtsuka K, Enomoto N, Watanabe M. Prediction of disease activity of Crohn's disease through fecal calprotectin evaluated by balloon-assisted endoscopy. J Gastroenterol Hepatol 2018; 33:1984-1989. [PMID: 29889986 DOI: 10.1111/jgh.14310] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 05/15/2018] [Accepted: 05/24/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Fecal calprotectin (FC) is a useful marker for assessing the activity of intestinal inflammation. However, most studies have used ileocolonoscopy to evaluate the association of FC with intestinal inflammation, and it is not clear whether FC is useful for the evaluation of small-bowel Crohn's disease (CD). This study aimed to determine the usefulness of FC for predicting intestinal inflammation evaluated by balloon-assisted endoscopy (BAE), which can visualize the deep small intestine. METHODS This was a cross-sectional, observational study involving 69 CD patients, 39 of whom had only small-bowel disease. The extended simplified endoscopic activity score for Crohn's disease (eSES-CD) was calculated based on the findings of BAE. Mucosal healing was defined as an eSES-CD of 0. RESULTS In all CD patients, FC levels were correlated with the eSES-CD (r = 0.663, P < 0.001). The cutoff value to predict mucosal healing was 92 mg/kg, with a sensitivity of 94%, specificity of 88%, positive predictive value of 98%, negative predictive value of 64%, and the area under the curve of 0.91. Even in small-bowel CD patients, FC levels were correlated with the eSES-CD (r = 0.607, P < 0.001). The cutoff value was 92 mg/kg, with a sensitivity of 87%, specificity of 88%, positive predictive value of 96%, negative predictive value of 64%, and area under the curve of 0.85. CONCLUSIONS Fecal calprotectin showed a significant correlation with the intestinal inflammation evaluated with BAE even in patients with only small intestinal disease. FC is useful for the evaluation of CD including both the small and large intestines.
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Affiliation(s)
- Fumihiko Iwamoto
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan.,First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Katsuyoshi Matsuoka
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Maiko Motobayashi
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toru Kuno
- First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Keisuke Tanaka
- First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Yuya Tsukui
- First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Shoji Kobayashi
- First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Takashi Yoshida
- First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Toshimitsu Fujii
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eiko Saito
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuya Yamaguchi
- First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tadashi Sato
- First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kazuo Ohtsuka
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobuyuki Enomoto
- First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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47
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Oshima S, Watanabe M. Genetic and environmental factors drive personalized medicine for Crohn's disease. J Clin Invest 2018; 128:4758-4760. [PMID: 30320603 DOI: 10.1172/jci124303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The introduction of anti-TNF antibody therapy has changed the course of treatment for Crohn's disease. However, the fundamental mechanism for the onset of Crohn's disease is still unknown, and the treatment strategy for this disease remains suboptimal. The assessment of the disease phenotype based on key environmental factors and genetic background may indicate options for the personalized treatment of Crohn's disease. In this issue of the JCI, Liu et al. show that consumption of tobacco and the mutation of ATG16L1T300A, a prevalent Crohn's disease susceptibility allele, drive defects in cells at the bottom of the intestinal crypt, the Paneth cells. These factors may provide novel targets for personalized medicine.
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48
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Taylor SA, Mallett S, Bhatnagar G, Baldwin-Cleland R, Bloom S, Gupta A, Hamlin PJ, Hart AL, Higginson A, Jacobs I, McCartney S, Miles A, Murray CD, Plumb AA, Pollok RC, Punwani S, Quinn L, Rodriguez-Justo M, Shabir Z, Slater A, Tolan D, Travis S, Windsor A, Wylie P, Zealley I, Halligan S. Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohn's disease (METRIC): a multicentre trial. Lancet Gastroenterol Hepatol 2018; 3:548-558. [PMID: 29914843 PMCID: PMC6278907 DOI: 10.1016/s2468-1253(18)30161-4] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Magnetic resonance enterography (MRE) and ultrasound are used to image Crohn's disease, but their comparative accuracy for assessing disease extent and activity is not known with certainty. Therefore, we did a multicentre trial to address this issue. METHODS We recruited patients from eight UK hospitals. Eligible patients were 16 years or older, with newly diagnosed Crohn's disease or with established disease and suspected relapse. Consecutive patients had MRE and ultrasound in addition to standard investigations. Discrepancy between MRE and ultrasound for the presence of small bowel disease triggered an additional investigation, if not already available. The primary outcome was difference in per-patient sensitivity for small bowel disease extent (correct identification and segmental localisation) against a construct reference standard (panel diagnosis). This trial is registered with the International Standard Randomised Controlled Trial, number ISRCTN03982913, and has been completed. FINDINGS 284 patients completed the trial (133 in the newly diagnosed group, 151 in the relapse group). Based on the reference standard, 233 (82%) patients had small bowel Crohn's disease. The sensitivity of MRE for small bowel disease extent (80% [95% CI 72-86]) and presence (97% [91-99]) were significantly greater than that of ultrasound (70% [62-78] for disease extent, 92% [84-96] for disease presence); a 10% (95% CI 1-18; p=0·027) difference for extent, and 5% (1-9; p=0·025) difference for presence. The specificity of MRE for small bowel disease extent (95% [85-98]) was significantly greater than that of ultrasound (81% [64-91]); a difference of 14% (1-27; p=0·039). The specificity for small bowel disease presence was 96% (95% CI 86-99) with MRE and 84% (65-94) with ultrasound (difference 12% [0-25]; p=0·054). There were no serious adverse events. INTERPRETATION Both MRE and ultrasound have high sensitivity for detecting small bowel disease presence and both are valid first-line investigations, and viable alternatives to ileocolonoscopy. However, in a national health service setting, MRE is generally the preferred radiological investigation when available because its sensitivity and specificity exceed ultrasound significantly. FUNDING National Institute of Health and Research Health Technology Assessment.
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Affiliation(s)
- Stuart A Taylor
- Centre for Medical Imaging, University College London (UCL), London, UK.
| | - Susan Mallett
- Institute of Applied Health Research, National Institute of Health and Research Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Rachel Baldwin-Cleland
- Intestinal Imaging Centre, St Mark's Hospital, London North West University Healthcare (LNWUH) National Health Service (NHS) Trust, Harrow, UK
| | - Stuart Bloom
- Department of Gastroenterology, University College Hospital, London, UK
| | - Arun Gupta
- Intestinal Imaging Centre, St Mark's Hospital, London North West University Healthcare (LNWUH) National Health Service (NHS) Trust, Harrow, UK
| | - Peter J Hamlin
- Department of Gastroenterology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ailsa L Hart
- Inflammatory Bowel Disease Unit, St Mark's Hospital, LNWUH NHS Trust, Harrow, UK
| | - Antony Higginson
- Department of Radiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Sara McCartney
- Department of Gastroenterology, University College Hospital, London, UK
| | - Anne Miles
- Department of Psychological Sciences, Birkbeck University of London, London, UK
| | - Charles D Murray
- Department of Gastroenterology and Endoscopy, Royal Free London NHS Foundation Trust, London, UK
| | - Andrew A Plumb
- Centre for Medical Imaging, University College London (UCL), London, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's Hospital, London, UK
| | - Shonit Punwani
- Centre for Medical Imaging, University College London (UCL), London, UK
| | - Laura Quinn
- Institute of Applied Health Research, National Institute of Health and Research Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Zainib Shabir
- Comprehensive Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, Holborn, London, UK
| | - Andrew Slater
- Department of Radiology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Damian Tolan
- Department of Radiology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon Travis
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | | | - Peter Wylie
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Ian Zealley
- Department of Radiology, Ninewells Hospital, Dundee, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London (UCL), London, UK
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49
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Rieder F, Bettenworth D, Ma C, Parker CE, Williamson LA, Nelson SA, van Assche G, Di Sabatino A, Bouhnik Y, Stidham RW, Dignass A, Rogler G, Taylor SA, Stoker J, Rimola J, Baker ME, Fletcher JG, Panes J, Sandborn WJ, Feagan BG, Jairath V. An expert consensus to standardise definitions, diagnosis and treatment targets for anti-fibrotic stricture therapies in Crohn's disease. Aliment Pharmacol Ther 2018; 48:347-357. [PMID: 29920726 PMCID: PMC6043370 DOI: 10.1111/apt.14853] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 04/19/2018] [Accepted: 05/26/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Fibrotic stricture is a common complication of Crohn's disease (CD) affecting approximately half of all patients. No specific anti-fibrotic therapies are available; however, several therapies are currently under evaluation. Drug development for the indication of stricturing CD is hampered by a lack of standardised definitions, diagnostic modalities, clinical trial eligibility criteria, endpoints and treatment targets in stricturing CD. AIM To standardise definitions, diagnosis and treatment targets for anti-fibrotic stricture therapies in Chron's disease. METHODS An interdisciplinary expert panel consisting of 15 gastroenterologists and radiologists was assembled. Using modified RAND/University of California Los Angeles appropriateness methodology, 109 candidate items derived from systematic review and expert opinion focusing on small intestinal strictures were anonymously rated as inappropriate, uncertain or appropriate. Survey results were discussed as a group before a second and third round of voting. RESULTS Fibrotic strictures are defined by the combination of luminal narrowing, wall thickening and pre-stenotic dilation. Definitions of anastomotic (at site of prior intestinal resection with anastomosis) and naïve small bowel strictures were similar; however, there was uncertainty regarding wall thickness in anastomotic strictures. Magnetic resonance imaging is considered the optimal technique to define fibrotic strictures and assess response to therapy. Symptomatic strictures are defined by abdominal distension, cramping, dietary restrictions, nausea, vomiting, abdominal pain and post-prandial abdominal pain. Need for intervention (endoscopic balloon dilation or surgery) within 24-48 weeks is considered the appropriate endpoint in pharmacological trials. CONCLUSIONS Consensus criteria for diagnosis and response to therapy in stricturing Crohn's disease should inform both clinical practice and trial design.
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Affiliation(s)
- Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Department of Pathobiology, Lerner Research Institute; Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Christopher Ma
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada,Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada
| | - Claire E. Parker
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada
| | - Lee A. Williamson
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada
| | - Sigrid A. Nelson
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada
| | - Gert van Assche
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Yoram Bouhnik
- Department of Gastroenterology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Ryan W. Stidham
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Frankfurt, Germany
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University of Zürich, Zürich, Switzerland
| | - Stuart A. Taylor
- Center for Medical Imaging, University College London, London, UK
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Jordi Rimola
- Department of Radiology, Centre de Diagnòstic per la Imatge (CDI), Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Mark E. Baker
- Imaging Institute/L10, Cleveland Clinic, Cleveland, OH, USA
| | | | - Julian Panes
- Institut d’Investigacions Biomèdiques August Pi i Sunyer-Hospital Clínic Barcelona, Barcelona, Catalonia, Spain
| | - William J. Sandborn
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G. Feagan
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
| | - Vipul Jairath
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
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50
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Lee JH, Park YE, Seo N, Lee HJ, Park SJ, Kim TI, Kim WH, Lim JS, Cheon JH. Magnetic resonance enterography predicts the prognosis of Crohn's disease. Intest Res 2018; 16:445-457. [PMID: 30090044 PMCID: PMC6077316 DOI: 10.5217/ir.2018.16.3.445] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/16/2017] [Accepted: 10/19/2017] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Magnetic resonance enterography (MRE) has emerged as an important tool in the diagnosis and follow-up of Crohn's disease (CD). The aim of this study was to evaluate whether MRE findings could predict the prognosis of CD. Methods In this retrospective study, a total of 173 patients with clinical remission of CD (n=61) or active CD (n=112) were identified. The outcomes of clinical relapse, admission, surgery, and need for other medications according to the MRE findings were evaluated. Results The presence of active inflammation on MRE was observed in 93 (83%) patients with clinically active CD and in 44 (72.1%) patients with clinical remission of CD, without a statistically significant difference (P=0.091). In multivariate analysis, active inflammation on MRE increased the risk for clinical relapse (hazard ratio [HR], 6.985; 95% confidence interval [CI], 1.024–47.649) in patients with clinical remission of CD. In patients with clinically active CD, active inflammation on MRE increased the risk for CD-related hospitalization (HR, 2.970; 95% CI, 1.006–8.772). Conclusions The presence of active inflammation on MRE was significantly associated with poor prognosis both in patients with clinical remission of CD and in those with active CD.
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Affiliation(s)
- Ji Hoon Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Eun Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Nieun Seo
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jung Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seok Lim
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
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