Relationships of capsule endoscopy Lewis score with clinical disease activity indices, C-reactive protein, and small bowel transit time in pediatric and adult patients with small bowel Crohn's disease

Assessment of IBD disease activity by Interleukin-6 and serum amyloid A in relation with fecal calprotectin and endoscopic indices

BACKGROUND AND STUDY AIMS

Close monitoring of disease activity in IBD patients is essential to avoid long term complications. Although endoscopic assessment is the ideal monitoring tool, the usage of noninvasive biomarkers is more practical and patient friendly. We aimed to study the performance of Interleukin-6(IL-6) and Serum Amyloid A(SAA) as serum biomarkers in assessment of the disease activity of IBD patients in correlation to C-reactive protein (CRP), Fecal Calprotectin (FC) and endoscopic indices.

METHODS

83 IBD (26 CD and 57 UC) patients on stable treatment regimen were recruited. Serum markers included CRP, CBC, IL-6, SAA were analyzed, together with FC. These markers were compared with the endoscopic and clinical disease parameters. Harvey-Bradshaw Index (HBI) and the Simple Clinical Colitis Activity Index (SCCAI) were used to assess clinical activity in CD and UC patients, respectively. Endoscopic activity was recorded using the Simple Endoscopic Score (SES) for Crohn's disease or the Mayo Endoscopic Score (MES) for ulcerative colitis.

RESULTS

In prediction of disease activity, IL-6, SAA and CRP demonstrated good area under receiver operating characteristics (AUC) (>0.7), with FC being the best (0.94) for endoscopically active disease (P < 0.01). Combining FC and IL-6 or SAA improved its discriminative accuracy with an AUC (∼0.96).

CONCLUSIONS

FC most accurately predicts endoscopic disease activity in IBD patients, in comparison to other studied serological biomarkers. The serum IL-6 and SAA are potential predictors of endoscopic disease activity, and they might be valuable for assessment of disease activity. Finally, a composite score of FC and SAA or IL-6 can increased its diagnostic accuracy.

Capsule Endoscopy versus Magnetic Resonance Enterography for Evaluation of Pediatric Small Bowel Crohn’s Disease: Prospective Study

Background: Magnetic resonance enterography (MRE) and capsule endoscopy (CE) are currently used for the evaluation of small bowel involvement in pediatric Crohn’s disease (CD). Several studies have been conducted to investigate the usefulness and diagnostic accuracy of each test. However, only a few studies have been conducted to compare the performance of both tests in the assessment of pediatric small bowel CD upon diagnosis and during follow-up. Therefore, the purpose of this study was to assess the diagnostic accuracy and diagnostic consistency of CE and MRE for the evaluation of pediatric small bowel CD at the time of diagnosis and during follow-up. Methods: Fifteen patients with pediatric CD were recruited for this study. They underwent MRE and CE concomitantly at the time of diagnosis and 10–12 weeks and one year after induction therapy for CD. MRE was interpreted using MRE global score (MEGS) and bowel wall inflammation severity diffusion-weighted imaging score (BWI-DWIS), whereas CE was interpreted using Lewis’s score (LS). The two diagnostic modalities were then compared. Results: Eleven patients completed MRE and CE at the time of diagnosis. Analysis of the results showed that LS had a strong correlation with MEGS and BIS-DWIS (ρ = 0.633, p = 0.037, and ρ = 0.629, p = 0.038, respectively). Nine patients completed three MREs and three CEs. LS significantly decreased throughout the sessions (p = 0.044), whereas MEGS and BIS-DWIS did not show any statistically significant changes. When LS was compared with MEGS and BIS-DWIS, both MRE indicators showed statistically significant differences throughout the sessions. Conclusions: At the time of diagnosis, the severity indexes of MRE and CE showed very good agreement. However, throughout management, MRE and CE did not show consistent changes.

Usefulness of ultrasonography for small intestinal evaluations in pediatric Crohn's disease

BACKGROUND

Small bowel capsule endoscopy (SBCE) for Crohn's disease is useful; however, its use has some limitations, such as invasiveness when endoscopic assistance is required in patients who cannot swallow the capsule, and the burden of interpretation on a physician. In contrast, intestinal ultrasonography (IUS) is a non-invasive modality for children. The purpose of this study is to evaluate the accuracy of IUS for pediatric patients with established Crohn's disease.

METHODS

Small bowel capsule endoscopy and IUS findings from the same period in pediatric patients with established Crohn's disease were analyzed retrospectively. First, we compared the Lewis score (LS), small bowel endoscopic activity, and IUS findings by small bowel wall thickness (SBWT) and mesenteric lymph node size (MLNS). Second, we compared the performance of IUS findings with those of some biomarkers.

RESULTS

In 22 procedures, SBWT and MLNS were correlated with LS (r = 0.52, P < 0.05, and r = 0.45, P < 0.05, respectively). Small bowel wall thickness, erythrocyte sedimentation rate, and fecal calprotectin levels had the highest accuracy (81.8%, 81.8%, and 81.8%, respectively). The combination of SBWT and MLNS had the highest positive predictive value and negative predictive value (100% and 83.3%, respectively).

CONCLUSIONS

Intestinal ultrasonography findings, including SBWT and MLNS, are useful for monitoring small bowel lesions in pediatric patients with established Crohn's disease. We suggest first evaluating small bowel inflammation by IUS in pediatric patients with Crohn's disease before SBCE because IUS is less invasive than SBCE.

Clinical features of capsule endoscopy in 825 children: A single-center, retrospective cohort study

Video capsule endoscopy (VCE) can detect mucosal lesions in the intestine, especially in the small bowel.Our study aims to evaluate the applications of VCE for pediatric gastrointestinal diseases.In this retrospective study, we included all patients who underwent VCE between December 2012 and December 2018. Clinical information and VCE data were analyzed.Among 828 patients, the completion rate was 99.6% (n = 825), with an average age of 10.2 ± 3.3 years old. A total of 459 VCE procedures showed abnormalities, and the overall diagnostic yield was 55.6%. The most common indications for VCE were abdominal pain among 505 (61.2%) patients and hematochezia (10.1%) among 83. Among the positive results of VCE, small bowel ulcers accounted for the highest percentage (57.7%), of which 164 cases were diagnosed as inflammatory bowel disease. For obscure gastrointestinal bleeding, 12 cases were diagnosed as Meckel's diverticulum. In terms of the small bowel transit time of VCE, compared with the negative group [288 (216.5, 390.3) min] and the enteritis group [277 (192.5, 374.8) min], a longer transit time was needed in the small bowel ulcer group [332.5 (240, 451.5) min, P < .01]. There were no correlations of positive VCE findings with anemia, the white blood cell count, the C-reactive protein level or the small bowel transit time according to Spearman rank analysis.VCE is relatively well tolerated and safe in children and has great value for the diagnosis and treatment of abdominal pain, especially inflammatory bowel disease and obscure gastrointestinal bleeding.

Small bowel capsule endoscopy and treat-to-target in Crohn's disease: A systematic review

BACKGROUND

Crohn's disease (CD) can affect the entire gastrointestinal tract. Proximal small bowel (SB) lesions are associated with a significant risk of stricturing disease and multiple abdominal surgeries. The assessment of SB in patients with CD is therefore necessary because it may have a significant impact on prognosis with potential therapeutic implications. Because of the weak correlation that exists between symptoms and endoscopic disease activity, the "treat-to-target" paradigm has been developed, and the associated treatment goal is to achieve and maintain deep remission, encompassing both clinical and endoscopic remission. Small bowel capsule endoscopy (SBCE) allows to visualize the mucosal surface of the entire SB. At that time, there is no recommendation regarding the use of SBCE during follow-up.

AIM

To investigate the impact of SBCE in a treat-to-target strategy in patients with CD.

METHODS

An electronic literature search was conducted in PubMed and Cochrane library using the following search terms: "capsule endoscopy", in combination with "Crohn's disease" and "treat-to-target" or synonyms. Two authors independently reviewed titles and abstracts identified by the search strategy after duplicates were removed. Following the initial screening of abstracts, all articles containing information about SBCE in the context of treat-to-target strategy in patients with CD were included. Full-text articles were retrieved, reference lists were screened manually to identify additional studies.

RESULTS

Forty-seven articles were included in this review. Two indexes are currently used to quantify disease activity using SBCE, and there is good correlation between them. SBCE was shown to be useful for disease reclassification in patients who are suspected of having or who are diagnosed with CD, with a significant incremental diagnostic yield compared to other diagnostic modalities. Nine studies also demonstrated that the mucosal healing can be evaluated by SBCE to monitor the effect of medical treatment in patients with CD. This review also demonstrated that SBCE can detect post-operative recurrence to a similar extent as ileocolonoscopy, and proximal SB lesions that are beyond the reach of the colonoscope in over half of the patients.

CONCLUSION

SBCE could be incorporated in the treat-to-target algorithm for patients with CD. Randomized controlled trials are required to confirm its usefulness and reliability in this indication.

Capsule endoscopy findings for the diagnosis of Crohn's disease: a nationwide case-control study

BACKGROUND

Capsule endoscopy can be used to identify the early stage of small bowel Crohn's disease (CD). We evaluated significant small bowel capsule endoscopy (SBCE) findings that can lead to early diagnosis of CD.

METHODS

We retrospectively accumulated clinical and SBCE data of 108 patients (63 with and 45 without CD). Types of small bowel mucosal injuries, including erosion, ulceration, and cobblestone appearance, and the alignment of diminutive lesions were compared between patients with and without CD. Inter- and intra-observer agreement in the determination of lesions was assessed in 25 pairs of SBCE from the two groups.

RESULTS

Under SBCE, cobblestone appearance (33% vs. 2%, p < 0.0001), longitudinal ulcers (78% vs. 20%, p < 0.0001), and irregular ulcers (84% vs. 60%, p < 0.01) were more frequently found in patients with CD. Linear erosion (90% vs. 38%, p < 0.0001) and irregular erosion (89% vs. 64%, p < 0.005) were also more frequent in patients with CD. Furthermore, circumferential (75% vs. 9%, p < 0.0001) and longitudinal (56% vs. 7%, p < 0.0001) alignment of diminutive lesions, mainly observed in the 1st tertile of the small bowel, was more frequent in patients with CD. Good intra-observer agreement was found for ulcers, cobblestone appearance, and lesion alignment. However, inter-observer agreement of SBCE findings differed among observers.

CONCLUSIONS

Circumferential or longitudinal alignment of diminutive lesions, especially in the upper small bowel, may be a diagnostic clue for CD under SBCE, while inter-observer variations should be cautiously considered when using SBCE.

Correlation of the endoscopic findings for small and large bowels in pediatric patients with established Crohn's disease

Small bowel capsule endoscopy can detect subtle mucosal lesions in pediatric patients with Crohn’s disease, and our aim was to evaluate its application in established ileocolonic Crohn’s disease. Colonic inflammation was evaluated with the colonic Simple Endoscopic Score for Crohn’s Disease (SES-CD) (excluding the score of the terminal ileum). Small bowel inflammation was evaluated with the Lewis score and/or Capsule Endoscopy Crohn’s Disease Activity Index (CECDAI). A Lewis score <135 was defined as small bowel inactive. A colonic SES-CD of 0 (colonic inactive group) was observed in 22/42 procedures (52.4%), and active small bowel lesions were observed in 11/22 procedures (50.0%). The Lewis score was lower in the colonic inactive group compared to the colonic active group. Correlations between the colonic SES-CD, the Lewis score and CECDAI were weak. The Lewis score and CECDAI in the colonic inactive group had significant correlation with fecal calprotectin levels. We suggest that Crohn’s disease patients without both colonic active lesions and elevation of fecal calprotectin levels may not need to receive small bowel capsule endoscopy due to low incidence of lesions in small bowel.

Capsule endoscopy: Current status and role in Crohn’s disease

Capsule endoscopy (CE) has proved to be an important non-invasive tool for diagnosis and monitoring Crohn’s disease patients. It has the advantage of excellent visualization of digestive tract mucosa, a good tolerability and safety in well-selected patients. The risk of retention can be diminished by good selection of patients using imaging techniques and by the use of patency capsule. The aim of a capsule examination is not only an early diagnosis but also a very good stratification of prognosis, thus directing the treatment strategy for either a step up or top-down approach and also permitting the optimization of the treatment depending on the findings. When symptoms and biomarkers point to a change in the disease’s activity we can either adjust the treatment directly as recommended in CALM study or choose in selected patients to visualize the digestive mucosa through a CE and take a decision afterwards. The appearance of the new capsule from Medtronic-the Pillcam Crohn’s might be an important step forward in diagnosis, evaluating disease extent, the severity of the disease, prognosis, management in a treat to target approach, with treatment modifications according to the data from CE examination. Serial examinations in the same patient can be compared and a more objective evaluation of the lesions modification from one exam to another can be performed. We present the latest developments and current status and evidence that in selected patients capsule can be a tool in a treat to target approach.