Clinical features, therapeutic requirements and evolution of patients with Crohn's disease and upper gastrointestinal involvement (CROHNEX study)

Diagnostic Procedures for Inflammatory Bowel Disease: Laboratory, Endoscopy, Pathology, Imaging, and Beyond

Diagnosing inflammatory bowel disease (IBD) can often be challenging, and differentiating between Crohn's disease and ulcerative colitis can be particularly difficult. Diagnostic procedures for IBD include laboratory tests, endoscopy, pathological tests, and imaging tests. Serological and stool tests can be easily performed in an outpatient setting and provide critical diagnostic clues. Although endoscopy is an invasive procedure, it offers essential diagnostic information and allows for tissue biopsy and therapeutic procedures. Video capsule endoscopy and device-assisted enteroscopy are endoscopic procedures used to evaluate the small bowel. In addition to endoscopy, magnetic resonance imaging, computed tomography, and ultrasound (US) are valuable tools for small bowel assessment. Among these, US is noninvasive and easily utilized, making its use highly practical in daily clinical practice. Endoscopic biopsy aids in the diagnosis of IBD and is crucial for assessing the histological activity of the disease, facilitating a thorough evaluation of disease remission, and aiding in the development of treatment strategies. Recent advances in artificial intelligence hold promise for enhancing various aspects of IBD management, including diagnosis, monitoring, and precision medicine. This review compiles current procedures and promising future tools for the diagnosis of IBD, providing comprehensive insights.

Distribution of small bowel involvement and its association with clinical outcomes in patients with Crohn's disease

We aimed to evaluate the distribution of small-bowel involvement in Crohn's disease (CD) and its association with clinical outcomes. This study included CD patients who underwent computed tomography (CT) at initial diagnosis from June 2006 to April 2021. Two abdominal radiologists reviewed the CT images, and independently rated the presence of "bowel wall thickening," "stricture," and "fistula or abscess" in the small bowel segments of jejunum, distal jejunum/proximal ileum, distal ileum, and terminal ileum, respectively. Based on findings of the image review, each patient's "disease-extent imaging score" and "behavior-weighted imaging score" (a higher score indicative of more structuring or penetrating disease) were calculated. Major clinical outcomes (emergency department [ED] visit, operation, and use of corticosteroids or biologics) were compared according to the 2 scores and L4 involvement by the Montreal classification. The proportions of involvement in the jejunum, distal jejunum/proximal ileum, distal ileum, and terminal ileum were 2.0%, 30.3%, 82.2%, and 71.7%, respectively, identifying 30.3% of patients as having L4 disease and 69.7% of patients as having involvement of multiple segments. Clinical outcomes were not significantly associated with the disease-extent imaging score or L4 involvement. However, significant differences were noted for the ED visits and the use of biologics, according to the behavior-weighted imaging score. Moreover, in multivariable analysis, disease behavior was the only factor associated with all clinical outcomes (ED visit, hazard ratio [HR] 2.127 [1.356-3.337], P = .001; operation, HR 8.216 [2.629-25.683], P < .001; use of corticosteroid, HR 1.816 [1.249-2.642], P = .002; and use of biologics, HR 2.352 [1.492-3.708], P < .001). Initial disease behavior seems to be a more critical factor for clinical outcomes of CD than the extent or distribution of small-bowel involvement on CT.

A systematic review and meta-analysis of prevalence and clinical features of upper gastrointestinal (UGI) tract Crohn's disease in adults compared to non-UGI types

Background and Aim

Crohn's disease is an inflammatory condition that affects the gastrointestinal (GI) system. This study aimed to determine the prevalence of upper gastrointestinal Crohn's disease (UGICD) and compare its features to non-UGICD types.

Methods

We conducted a systematic search in the databases PubMed, Web of Science, Scopus, and Google Scholar. The heterogeneity of prevalence estimates was examined, subgroup analyses were carried out, and meta-analyses were conducted using random-effects modeling. Prognostic data were qualitatively reviewed and combined.

Results

Two-thousand nine-hundred and forty studies were retrieved and 32 studies were included in the final analysis. Pooled prevalence of UGICD was 15% (CI: 11-18%) among 14 509 patients. UGICD prevalence did not show any significant increase with time (P = 0.45). The most prevalent (38%, CI: 30-47%) behavior of UGICD was B1 (nonstricturing-nonpenetrating), while the most common concurrent location was L3 (ileocolon) with a prevalence of 47% (CI: 34-59%). UGICD patients had higher stricturing phenotype (B2) compared to non-UGICD (0.38 vs 0.30; P = 0.03). There was no significant difference in the prevalence of UGICD between patients classified according to the Montreal or Vienna classification. Stricturing phenotype was more common among Asian patients compared to Western patients (0.44 vs 0.24; P < 0.001). UGICD was a risk factor for surgery and drug therapy and was associated with an aggressive course of the disease and more resections. Pooled prevalence of UGICD was 15%.

Conclusion

Nonstricturing-nonpenetrating type was the most prevalent UGICD. UGICD patients had more complications and worse outcomes compared to non-UGICD patients.

Small bowel Crohn's disease: optimal modality for diagnosis and monitoring

PURPOSE OF REVIEW

This paper reviews different imaging options for small bowel (SB) Crohn's disease (CD) patients.

RECENT FINDINGS

In total, 80% of patients suffering from CD have SB involvement, being the exclusive manifestation in 30% of cases. As the proximal disease is related to poor response to treatment, a higher rate of stenosis and a greater need for surgical treatment, a SB assessment should be performed. This evaluation should be done not only once the disease has been diagnosed but periodically. The former to determine the extent of the disease, and the latter according to a treat-to-target strategy. Available techniques such as magnetic resonance imaging, intestinal ultrasound and capsule endoscopy (CE) have shown good accuracy parameters in CD patients. Cross-sectional studies are superior for penetrating and stricturing disease, whereas CE is excellent for proximal involvement and mucosal healing. Local expertise and availability may lead the election between techniques, nevertheless, they should not be considered as competitors but as complementary tools.

SUMMARY

SB involvement in CD patients is frequent and related to poorer outcomes. Hence, SB evaluation should be screened after diagnosis and routinely during the follow-up.