Capsule endoscopic findings correlate with fecal calprotectin and C-reactive protein in patients with suspected small-bowel Crohn's disease

Association between body mass index and fecal calprotectin levels in children and adolescents with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common pediatric functional gastrointestinal disorder. It is characterized by recurrent abdominal pain and changes in bowel habits and is more prevalent in obese patients. We investigated the association between obesity and IBS in pediatric patients through fecal calprotectin testing. Patients under 18 years of age with IBS who underwent fecal calprotectin testing from January 2015 through April 2020 were retrospectively investigated. The patients were divided into groups based on body mass index (BMI): group I (BMI < 85th percentile) and group II (BMI ≥ 85th percentile). Group II was divided into group IIa, overweight (85th percentile ≤ BMI < 95th percentile), and group IIb, obese (BMI ≥ 95th percentile). Among 277 included patients, 202 (72.9%) were in group I, and 75 (27.1%) were in group II (mean calprotectin levels, 75.60 ± 103.48 vs 45.89 ± 66.57 µg/g, respectively; P = .006). There were significant differences in mean calprotectin levels between groups I and IIa (75.60 ± 103.48 vs 45.45 ± 63.38 µg/g, respectively; P = .028) and groups I and IIb (75.60 ± 103.48 vs 46.22 ± 69.59 µg/g, respectively; P = .025). There was a significant difference in mean calprotectin levels between groups I and II (85.69 ± 142.13 vs 32.04 ± 28.17 µg/g, respectively; P = .029) among patients between 6 and 12 years of age but not among adolescents aged between 12 and 18 years (P = .139). Fecal calprotectin was lower when moderate-to-severe fatty livers were observed by ultrasound compared with normal livers (68.52 ± 97.22 vs 18.53 ± 18.56 µg/g, respectively; P = .017). Fecal calprotectin levels were higher in normal-weight pediatric IBS patients than in their obese counterparts, and this difference was more prominent in younger patients. In young children, IBS symptoms are thought to be influenced more by factors other than intestinal inflammation.

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.

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.

The role of small-bowel endoscopy in inflammatory bowel disease: an updated review on the state-of-the-art in 2021

The impact of small-bowel (SB) capsule endoscopy and device-assisted enteroscopy on clinical practice, since their introduction 2 decades ago, has been remarkable. These disruptive technologies have transformed the investigation and management of SB pathology and now have a firmly established place in guidelines and clinical algorithms. Furthermore, recent years have witnessed innovations, driven by the demand of new goals in the management of inflammatory bowel disease (IBD), such as mucosal healing and evolving strategies based on tight monitoring and accelerated escalation of care. These developments in SB endoscopy have also been paralleled by refinement in dedicated radiological SB imaging technologies. This updated review highlights the current state of the art and more recent innovations with a focus on their role in IBD.

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

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

Usefulness of the capsule endoscopy Crohn's disease activity index in assessing the necessity of early additional treatment in patients with Crohn's disease in clinical remission

The Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) was recently reported as a new scoring system to evaluate the mucosal lesions of patients with Crohn's disease (CD). We investigated whether CECDAI is useful for assessing the necessity of early additional treatment in patients with CD in clinical remission.Twenty-one patients with small intestinal CD in clinical remission underwent capsule endoscopy (CE). The CECDAI and Lewis score (LS) were used to evaluate the intestinal lesions. We analyzed the correlations between several biomarkers and CECDAI or LS and examined the changes in therapeutic regimens based on the CECDAI.CE identified intestinal abnormalities in most CD patients in clinical remission: 81.0% and 85.7%, as assessed using CECDAI and LS, respectively. A significant positive correlation was observed between the CDAI and LS (P = .025), as well as between CDAI and CECDAI (P = .014) in these cases. Compared to LS, CECDAI scores were more evenly distributed. No significant correlations were observed between endoscopic scores and serum markers, including CRP, hemoglobin, and albumin levels. Additional treatment was performed significantly more often in patients with moderate-severe disease activity (CECDAI ≥5.8) (P = .012) than in those with normal (CECDAI <3.5) and mild (3.5≤CECDAI<5.8) disease activity. Resection of the small intestine did not affect the small bowel transit time or CE score.CECDAI is useful in evaluating mucosal lesions in small bowel CD patients in clinical remission and helps in assessing the requirement for additional treatment for these patients, including those who undergo intestinal resection.

From terminal ileitis to Crohn's disease: how capsule endoscopy is crucial to diagnosis

BACKGROUND AND AIMS

Terminal ileitis is a common condition and may be associated with a wide variety of diseases, mostly Crohn's disease. Although small bowel capsule endoscopy (SBCE) is a valuable diagnostic tool for small-bowel diseases, data regarding its diagnostic impact on isolated terminal ileitis are sparse. The aim of this study was to evaluate the diagnostic value of SBCE for isolated terminal ileitis detected during ileocolonoscopy and to assess predictive factors for Crohn's disease diagnosis.

METHODS

This is a retrospective study including consecutive patients undergoing SBCE after diagnosis of terminal ileitis without colonic mucosal abnormalities on ileocolonoscopy between January 2016 and September 2019.

RESULTS

This included 102 patients with isolated terminal ileitis on ileocolonoscopy. Positive findings on SBCE were found in 82.4% of patients. After performing SBCE, 61.8% of patients had a final diagnosis, being Crohn's disease the most common (34.3%), followed by NSAIDs enteropathy (12.7%). Extraintestinal manifestations (P = 0.003), weight loss (P = 0.02), abnormal imaging (P = 0.04) and positive SBCE findings (P = 0.001) were independently associated with Crohn's disease diagnosis. Regarding SBCE, presence of proximal small-bowel disease (P = 0.02), diffuse findings (P = 0.002) and moderate to severe inflammatory activity (Lewis score ≥ 790) (P < 0.001) were independently associated with Crohn's disease diagnosis.

CONCLUSION

SBCE is a valuable tool that should be systematically used in patients with isolated terminal ileitis on ileocolonoscopy, since it revealed a high diagnostic yield, supporting a definite diagnosis in almost two-thirds of patients, and Crohn's disease diagnosis in approximately one-third of patients. A diagnosis of Crohn's disease should be considered when a patient with terminal ileitis on ileocolonoscopy shows proximal involvement, diffuse findings and/or moderate to severe inflammatory activity on SBCE.

Role of Capsule Endoscopy in Inflammatory Bowel Disease

In Crohn disease (CD), the use of capsule endoscopy (CE) for suspected versus established disease is very different. Most patients with CD are diagnosed with ileocolonoscopy. In patients with a negative ileocolonoscopy, CE is the next best test in suspected CD. In patients with established CD, the potential benefits of CE are rating severity of disease, establishing extent and distribution, and following mucosal healing in a treat to target strategy. In those with proximal small bowel disease, CE can help in diagnosis and prognostication. In ulcerative colitis, CE has a limited role, but that may change with evolving technology.

Characterization of Mucosal Lesions in Crohn's Disease Scored With Capsule Endoscopy: A Systematic Review

Background and Aims: There is little agreement on the nomenclature and description of Crohn's disease (CD) lesions that can be found in the small and large bowel using capsule endoscopy (CE). We performed a systematic review to identify mucosal lesions that have been described using CE in CD, in both the small bowel and colon, with the aim to make propositions to homogenize such descriptions.

Methods: A systematic literature search was conducted using Embase, Medline (OvidSP), and Cochrane Central on August 6, 2019. Clinical studies providing nomenclature and descriptions for small bowel and colonic inflammatory lesions using CE in CD were selected for data collection.

Results: In total, 851 articles were included for abstract screening out of which 219 were analyzed for full-text review. Twenty-two articles were selected for data extraction. Seven items, accompanied by clear descriptions, were found for the small bowel: i.e., ulcer, erosion, aphthoid lesion, edema, fissure, cobblestone appearance, and villous atrophy. No studies were found describing inflammatory items using CE in colonic CD.

Conclusions: The most frequently described CD lesions using CE were ulcers and erosions. Subjective interpretation of CE inflammatory findings plays an important role. Based on our findings, a range of suggestions regarding items and descriptions is made that might form the basis of a pan-enteric CE activity index.

Fecal calprotectin as a marker of gastrointestinal involvement in pediatric Henoch-Schönlein purpura patients: a retrospective analysis

Background

Henoch–Schönlein purpura is a type of systemic vasculitis found in children. Its prognosis is usually good; however, recurrence is relatively common. If the intestines are affected, severe complications could arise. Here, we investigated the value of fecal calprotectin in the early screening of Henoch–Schönlein purpura and as a useful factor for predicting gastrointestinal manifestations.

Methods

We retrospectively reviewed the medical records of pediatric patients who were diagnosed with Henoch–Schönlein purpura and underwent fecal calprotectin testing during the acute phase. The patients were categorized into gastrointestinal involvement and non-gastrointestinal involvement groups based on their clinical symptoms. Moreover, gastrointestinal involvement was categorized as follows: upper gastrointestinal tract involvement (up to the duodenum) and lower gastrointestinal tract involvement (from the terminal ileum).

Results

A total of 69 patients were diagnosed with Henoch–Schönlein purpura and underwent fecal calprotectin testing. Among them, 40 patients (58.0%) showed signs of gastrointestinal involvement. The gastrointestinal involvement group had higher fecal calprotectin levels (379.9 ± 399.8 vs. 77.4 ± 97.6 mg/kg, P = 0.000). There were no significant differences in the recurrence of Henoch–Schönlein purpura symptoms or gastrointestinal symptoms. The cut-off value to identify gastrointestinal involvement was 69.10 mg/kg (P < 0.01). Patients with fecal calprotectin levels of > 50 mg/kg showed more frequent gastrointestinal involvement (77.8% vs. 20.8%, P = 0.000) and more severe gastrointestinal symptoms. Significant differences in abdominal pain duration, Henoch–Schönlein purpura clinical score, and abdominal pain severity were observed (P = 0.002, P = 0.000, and P = 0.000, respectively). Additionally, fecal calprotectin levels were significantly higher in patients with lower gastrointestinal tract involvement (214.67 ± 150.5 vs. 581.8 ± 510.1 mg/kg, P = 0.008), and the cut-off value was 277.5 mg/kg (P < 0.01).

Conclusion

Fecal calprotectin testing is useful for identifying gastrointestinal involvement in pediatric Henoch–Schönlein purpura patients.

Is fecal calprotectin an accurate marker in the management of Crohn's disease?

Although lacking validated cutoff values, fecal calprotectin (FC), besides C-reactive protein, is considered the standard test for assessing disease activity in Crohn's disease (CD). The aim of the present review is to provide a general overview of the literature addressing the role of FC in the clinical and endoscopic assessment of disease activity in CD, seeking correlations with capsule endoscopy, response to therapy, prediction of relapse, and postoperative recurrence. A systematic search of the literature up to September 2019 was performed using Medline, Embase, and the Cochrane Library. Only papers written in English concerning FC in adult patients affected by CD were included. Pediatric studies, in vitro studies, animal studies, studies on blood/serum samples, and studies analyzing FC in ulcerative colitis or in both CD and ulcerative colitis were excluded. Out of 713 citations, 65 eligible studies were identified. FC showed high accuracy in the assessment of intestinal inflammation and response to therapy, in particular in colonic disease, thus proving a good surrogate marker for these aims. FC is useful in identifying patients at high risk for endoscopic relapse or postoperative recurrence, for optimizing or downstage therapy. Unfortunately, FC performs less well in small bowel CD. FC is an effective fecal marker in the management of CD patients, optimizing the use of endoscopic procedures. Owing to its diagnostic accuracy, FC may represent a cornerstone of the "treat-to-target" management strategy of CD patients.

How should we select suspected Crohn's disease patients for capsule enteroscopy?

Background: In suspected Crohn's disease (CD), non-diagnostic ileocolonoscopies are often followed by small bowel capsule endoscopy (SBCE). Adequate pre-selection of patients for SBCE is a key to optimize allocation of resources. We aimed to establish a rational approach for the CD diagnostic workflow, based on biochemical profile of patients with suspected CD, targeting an optimization of patients' selection for SBCE. Methods: Multicenter cohort study includes consecutive patients with suspected undergoing SBCE after non-diagnostic ileocolonoscopy. Minimum follow-up period after the capsule enteroscopy was six months. The outcome was confirmation of CD diagnosis. Univariate analysis and logistic regression were performed. Results: In included 220 patients, 62.3% of women were with a mean age of 41 years [26-54]. A confirmed diagnosis of CD was established in 98 patients (44.5%). The initial univariate analysis identified variables above the threshold of marginal statistical association toward CD diagnosis (p < .15). The regression model identified high CRP levels (OR 1.028 p = .128) and low serum Iron (OR 0.990 p = .025) as the independent variables with consistent correlation with CD diagnosis. Those two variables present a suitable discriminative power (AUC = 0.669, p < .001) for the diagnosis of CD. Conclusion: In suspected CD, low serum iron and elevated CRP had a statistically significant association with CD diagnosis, being helpful to identify patients with higher CD probability before SBCE. However, the lack of a proper validation of the model leads us to currently recommend SBCE to all patients with suspected CD and negative ileocolonoscopy, as no specific biochemical profile can be used to confidently exclude small bowel CD.

Influence of proton pump inhibitor therapy on intestinal inflammation assessed by fecal calprotectin in pediatric patients

BACKGROUND

An increase in the numbers of patients with gastrointestinal symptoms has recently been observed.

PURPOSE

To investigate the effects of proton pump inhibitor (PPI) therapy on intestinal inflammation in children and adolescents as confirmed by clinical manifestations and objectively assessed by fecal calprotectin (FC) level measurement.

METHODS

Consecutive children (aged 3-18 years) who presented with gastrointestinal symptoms and were treated with or without PPI for at least 1 month were enrolled. Patients were divided into PPI and non-PPI groups. The PPI group was further subdivided by treatment duration and type of PPI used. Stool samples were collected for FC evaluation at baseline and after treatment and clinical data and FC levels were compared between the groups.

RESULTS

Fifty-one patients (15 boys, 36 girls) were enrolled in the study. The PPI group included 37 patients, while the non-PPI group included 14 patients. Clinical symptoms were not significantly different. FC levels and laboratory results, including C-reactive protein levels, white blood cell count, and absolute neutrophil count, were not statistically different before versus after PPI treatment. After treatment, FC levels decreased to 8.1 mg/kg (-575.4 to 340.3 mg/kg) in the PPI group and increased to 5.6 mg/kg (-460.0 to 186.9 mg/kg) in the non-PPI group compared to those before treatment (P=0.841). The number of patients with increased FC levels was not significantly different between the 2 groups (48.6% vs. 64.3%, P=0.363), similar to that observed in patients with an FC level > 50 mg/kg (24.3% and 7.1%, P=0.250). PPI therapy type and duration did not affect the FC levels (P=0.811 and P=0.502, respectively).

CONCLUSION

Although we aimed to confirm the evidence of intestinal inflammation due to PPI use in children and adolescents through clinical symptoms and FC measurement, no significant changes were observed.

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.

Use of biomarkers in inflammatory bowel disease

There are many useful biomarkers for initial diagnosis and the management of inflammatory bowel disease. Serologic biomarkers have been traditionally used because they are widely disposable, but recently faecal biomarkers, especially faecal calprotectin, have acquired great importance as they have shown to be more precise when establishing suspicion of the disease and also as predictors of mucosal healing or persistence of inflammatory activity. Faecal calprotectin is a good tool for predicting abnormal endoscopic studies, but has limited specificity because its levels can be altered in many digestive diseases presenting with similar symptoms. The precision of faecal calprotectin is higher when associated with other altered parameters, especially with C-reactive protein, or with clinical scores of inflammatory activity. Finally, there are many new generation serologic and faecal biomarkers. Despite there not being much evidence about these yet, some of them have shown promising results in different studies.

Fecal Calprotectin as a Selection Tool for Small Bowel Capsule Endoscopy in Suspected Crohn's Disease

BACKGROUND

Small bowel capsule endoscopy (SBCE) is a firstline examination in patients with suspected Crohn's disease (CD) after negative ileocolonoscopy. Fecal calprotectin (FC) is a noninvasive marker of intestinal inflammation. The aim of this study was to evaluate the predictive value of FC in inflammatory activity detected by SBCE in patients with suspected CD.

METHODS

This is a retrospective study including patients who underwent SBCE for suspected CD between March 2015 and October 2016. FC was measured within 1 week of SBCE. Inflammatory activity at SBCE was considered significant when the Lewis score (LS) was ≥135. FC correlation with LS was assessed using the Spearman correlation. The diagnostic accuracy of FC for significant inflammatory activity at SBCE was calculated by the area under the receiver operating characteristic curve (AUC).

RESULTS

Seventy-five patients were included: 52 females (69.3%), with a mean age of 37 years. SBCE detected significant inflammatory activity (LS ≥ 135) in 42 patients (56%), and FC was positively correlated to LS (rank correlation = 0.56; P < 0.001). The AUC of FC was 0.854 for significant inflammatory activity (LS ≥ 135). For values of FC ≥100 µg/g, an LS ≥135 was found in 33 of 37 patients (89.2%, P < 0.001), corresponding to a sensitivity, specificity, positive predictive value, and negative predictive value of 78.6%, 87.9%, 89.2%, and 76.3%, respectively.

CONCLUSIONS

FC has shown a good ability to predict significant inflammatory activity in SBCE in patients with suspected CD. Thus, FC proved to be a useful tool to select patients with suspected CD for SBCE.

Association of clinical and inflammatory markers with small bowel capsule endoscopy findings in Crohn's disease

BACKGROUND

Mucosal healing is an established treatment endpoint in Crohn's disease (CD). Still, clinical indices and inflammatory markers are used widely in CD surveillance.

AIM

The aim of this study was to investigate the diagnostic performance as well as the relationship of C-reactive protein (CRP) and Crohn's Disease Activity Index (CDAI) with small bowel capsule endoscopy's (SBCE) inflammation scoring index, the Lewis Score (LS).

PATIENTS AND METHODS

CDAI, CRP, and SBCE findings of 30 CD patients with isolated small bowel disease were retrieved from our academic institution patient records and were analyzed statistically.

RESULTS

SBCE showed significant mucosal inflammation [mean (SD) LS: 1599 (1380)], in nine (60.0%) of 15 patients who were in both clinical and biochemical remission. CDAI and CRP showed a weak and moderate correlation with LS (r=0.317, P=0.088 and r=0.516, P=0.004, respectively). The diagnostic performance of CDAI and CRP in predicting mucosal inflammation was as follows: sensitivity 23.8 and 52.4%; specificity 100 and 66.7%; positive predictive value 100 and 78.6%; and negative predictive value 36.0 and 37.5%. The area under the curve toward endoscopic activity prediction was 0.70 and 0.69, respectively.

CONCLUSION

Both CDAI and CRP underestimated endoscopic activity as expressed by the LS in a significant proportion of patients with quiescent disease.

Development and validation of a scoring index to predict the presence of lesions in capsule endoscopy in patients with suspected Crohn's disease of the small bowel: a Spanish multicenter study

BACKGROUND

Capsule endoscopy (CE) is the first-line investigation in cases of suspected Crohn's disease (CD) of the small bowel, but the factors associated with a higher diagnostic yield remain unclear.

OBJECTIVE

Our aim is to develop and validate a scoring index to assess the risk of the patients in this setting on the basis of biomarkers.

PATIENTS AND METHODS

Data on fecal calprotectin, C-reactive protein, and other biomarkers from a population of 124 patients with suspected CD of the small bowel studied by CE and included in a PhD study were used to build a scoring index. This was first used on this population (internal validation process) and after that on a different set of patients from a multicenter study (external validation process).

RESULTS

An index was designed in which every biomarker is assigned a score. Three risk groups have been established (low, intermediate, and high). In the internal validation analysis (124 individuals), patients had a 10, 46.5, and 81% probability of showing inflammatory lesions in CE in the low-risk, intermediate-risk, and high-risk groups, respectively. In the external validation analysis, including 410 patients from 12 Spanish hospitals, this probability was 15.8, 49.7, and 80.6% for the low-risk, intermediate-risk, and high-risk groups, respectively.

CONCLUSION

Results from the internal validation process show that the scoring index is coherent, and results from the external validation process confirm its reliability. This index can be a useful tool for selecting patients before CE studies in cases of suspected CD of the small bowel.

Elevated Faecal Calprotectin Levels are a Reliable Non-Invasive Screening Tool for Small Bowel Crohn's Disease in Patients Undergoing Capsule Endoscopy

BACKGROUND

Approximately 10% of Crohn's disease (CD) patients have this disease affecting the small bowel (SB) beyond the reach of Ileo-colonoscopy. Capsule endoscopy (SBCE) is the recommended investigation for SB disease. An accurate and inexpensive biomarker would help identify at-risk patients.

AIM

To examine the efficacy of faecal calprotectin (FC) and C-reactive protein (CRP) as predictors of SBCE findings in suspected and known CD.

METHODS

A prospective observational study. Consecutive patients referred for SBCE gave FC and CRP samples. The diagnostic accuracy for SB CD based on SBCE result was calculated for both FC and CRP.

RESULTS

Of 100 invitees, FC and SBCE results were available in 64 cases. Correlation between FC >50 µg/g and SBCE result was poor К = 0.163; sensitivity, specificity, positive predictive value (PPV) and negative predictive values for ileitis were 60, 61, 32 and 83% respectively. PPV and specificity improved at FC >100 µg/g, 76 and 40%, correlation remained fair, К = 0.259. Receiver operating characteristic analysis had a sensitivity of 47% and specificity of 90% for FC >194 µg/g. CRP alone or in combination was an inaccurate predictor of ileitis.

CONCLUSION

Our study suggests that FC level >194 µg/g may be a useful SBCE filter test, identifying patients at risk of SB CD.

Fecal calprotectin and C-reactive protein are associated with positive findings in capsule endoscopy in suspected small bowel Crohn's disease

BACKGROUND AND AIM

Capsule endoscopy is an extended tool for the diagnosis of small bowel Crohn's disease. However, factors associated with positive findings of this technique have not been well established. Our aim is to asses which factors are associated with a better diagnostic yield of capsule endoscopy in suspected small bowel Crohn's disease.

MATERIAL AND METHODS

This was a retrospective study including patients under capsule endoscopy because of suspected small bowel Crohn's disease. Demographic data of these patients, as well as symptoms and laboratory data including hemoglobin levels, count of leucocytes and platelets, and levels of C-reactive protein, erythrocyte sedimentation rate and fecal calprotectin were collected. Capsule endoscopy studies were classified as negative (no lesions) or positive (lesions suggestive of Crohn's disease). Descriptive, univariate and multivariate analysis were done, as well as diagnostic yield tests of the different markers for predicting lesions in capsule studies.

RESULTS

One hundred and twenty-four patients were included (85 women and 39 men). The average age was 38.21 years. Levels of C-reactive protein and fecal calprotectin were the markers more frequently associated with positive findings in capsule endoscopy. Calprotectin presented the best sensitivity as isolated marker. The association of altered levels of C-reactive protein and calprotectin showed the best specificity and predictive values.

CONCLUSIONS

C-reactive protein and fecal calprotectin are appropriate biomarkers for selecting patients with suspected Crohn's disease of the small bowel for capsule endoscopy studies.

Faecal biomarkers for screening small bowel inflammation in patients with Crohn's disease: a prospective study

BACKGROUND

The value of faecal biomarkers for screening small bowel inflammation in patients with Crohn's disease (CD) remains to be elucidated. This prospective study was to evaluate the utility of faecal biomarkers for detecting small intestinal inflammation.

METHODS

A total of 122 consecutive patients with a diagnosis of CD in the small intestine were screened for eligibility. Computed tomography enterography (CTE) was undertaken to evaluate small bowel inflammation followed by colonoscopy to confirm no large bowel involvement. Seventy eligible patients with inflammation confined to the small intestine were included. Faecal samples were collected for assaying calprotectin, lactoferrin and haemoglobin. For assessing the degree of small bowel inflammation, a semi-quantitative scoring system (CTE0, normal; CTE1, mild; CTE2, moderate; CTE3, severe) was applied.

RESULTS

The median calprotectin, lactoferrin and haemoglobin levels were significantly higher in patients with small bowel inflammation, CTE scores 1-3 (n = 42) versus 0 (n = 28): calprotectin, 330 versus 40 ng/ml, p < 0.0001; lactoferrin, 14 versus 3 ng/ml, p < 0.0001; haemoglobin, 29.5 versus 6.5 ng/ml, p = 0.005. There was a strong positive relationship between the faecal biomarkers and CTE score: calprotectin, p < 0.0001; lactoferrin, p < 0.0001; haemoglobin, p = 0.0004. A cutoff value of 140 ng/ml for calprotectin had a sensitivity of 69% and a specificity of 82% with an area under the receiver operating characteristic curve (AUC) of 0.82 to detect small bowel inflammation (CTE scores 1-3), while lactoferrin 6 ng/ml had a sensitivity of 69% and a specificity of 79% with an AUC of 0.83, and haemoglobin 9 ng/ml showed a sensitivity of 71% and a specificity of 39% with an AUC of 0.70.

CONCLUSIONS

Faecal calprotectin, lactoferrin, and to a lesser degree haemoglobin are relevant biomarkers for screening small bowel inflammation in CD patients without large bowel involvement. Further well-designed large-scale studies in this clinical setting should strengthen our findings.

Effects of Transient and Persistent Anti-drug Antibodies to Certolizumab Pegol: Longitudinal Data from a 7-Year Study in Crohn's Disease

BACKGROUND

Anti-drug antibodies (ADAbs) may decrease the efficacy of biologics and increase the risk of adverse events. A single positive test may not preclude further treatment because of variations in assays used, test timing, and patient variables. We evaluated the longitudinal patterns of immunogenicity during 7 years of antitumor necrosis factor-alpha drug certolizumab pegol (CZP) treatment for moderate-to-severe Crohn's disease.

METHODS

PRECiSE 3 patients (n = 595) received open-label CZP 400 mg every 4 weeks up to 7 years. CZP-ADAb expression, plasma CZP concentration, Harvey-Bradshaw Index, C-reactive protein, and fecal calprotectin concentrations were measured multiple times. Longitudinal data, examined for CZP-ADAb positivity and categorized as transient (with temporary/no effect on CZP concentration), persistent, or negative, were correlated with clinical and biological variables.

RESULTS

Of the CZP-ADAb-positive patients, 40 (22.6%) had transient CZP-ADAbs and 94 (77.4%) had persistent CZP-ADAbs. Demographic characteristics were similar between groups. Median C-reactive protein and fecal calprotectin were higher (P < 0.05 at some visits) and plasma CZP concentrations were significantly lower (P < 0.0001 at all visits) in the persistent CZP-ADAb-positive group relative to the CZP-ADAb-negative group. Transient CZP-ADAb-positive and CZP-ADAb-negative patients had similar plasma CZP, C-reactive protein, and fecal calprotectin concentrations. Median Harvey-Bradshaw Index scores and rates of adverse events were similar among groups.

CONCLUSIONS

This analysis demonstrates that persistent CZP-ADAb has negative effects on drug levels and efficacy, whereas transient expression may not. Serial measurements may be needed to characterize ADAb positivity. www.clinicaltrials.gov, Number NCT00160524.

A prospective study of fecal calprotectin and lactoferrin as predictors of small bowel Crohn's disease in patients undergoing capsule endoscopy

BACKGROUND

Capsule endoscopy (CE) is often used to investigate small bowel Crohn's disease (CD).

AIM

The aim of this study is to prospectively assess the value of fecal calprotectin and lactoferrin to predict CE findings.

PATIENTS AND METHODS

Sixty-eight consecutive patients that were referred for CE were included. Stool samples for calprotectin and lactoferrin and blood samples were collected for relevant parameters. Correlation between fecal markers and CE findings was assessed and receiver operating characteristic (ROC) curves were built to determine the predictive values of fecal markers for the diagnosis of CD.

RESULTS

Fecal calprotectin data was available for all the patients and lactoferrin data for 38. CE findings compatible with CD were found in 23 (33%) patients and 45 (67%) were negative for CD. The average age of the CD group was 34 compared to 46 in the non-CD group (p = .048). Median calprotectin and lactoferrin in the CD group and in the control group were 169 mg/kg vs. 40 (p = .004) and 6.6 mg/kg vs. 1 (p = .051), respectively. The area under the ROC curve was 0.767 for calprotectin and 0.70 for lactoferrin. A fecal calprotectin concentration of 95 mg/kg and fecal lactoferrin of 1.05 mg/kg had a sensitivity, specificity, positive predictive value and negative predictive value of 77 and 73%, 60 and 65%, 50 and 50%, and 84 and 84% in predicting CE findings compatible with CD.

CONCLUSIONS

Fecal markers are simple and noninvasive surrogates for predicting CE findings compatible with CD. Fecal markers can help determine which patients should be referred for CE. ClinicalTrials.gov Identifier: NCT01266629.

Inflammatory Disorders of the Small Bowel

The most common small bowel inflammatory disorders include Crohn disease, nonsteroidal antiinflammatory drug (NSAID) enteropathy, and celiac disease. Capsule endoscopy, computed tomography enterography, and magnetic resonance enterography have a complementary role in the diagnosis of Crohn disease and evaluation of patients with established Crohn disease. The higher risk of capsule retention with known Crohn disease and NSAID enteropathy can be minimized by cross-sectional imaging or the patency capsule. The main role of deep enteroscopy is tissue diagnosis, endoscopic management of small bowel lesions and strictures, and retrieval of retained capsules.

The diagnostic accuracy of faecal calprotectin and small bowel capsule endoscopy and their correlation in suspected isolated small bowel Crohn's disease

INTRODUCTION

Faecal calprotectin (FC) is less accurate at identifying inflammation in the small bowel than in the colon. Small bowel capsule endoscopy (SBCE) is a useful tool to detect small bowel inflammation. We investigated the diagnostic accuracy of FC and SBCE and their correlation in patients with suspected isolated small bowel Crohn's disease.

PATIENTS AND METHODS

This was performed as a prospective single centre study including patients attending for SBCE with suspected small bowel Crohn's disease. Patient demographics, symptoms, medications and blood parameters were collected. Capsule endoscopy findings were analysed against calprotectin values, final diagnosis and blood parameters.

RESULTS

A total of 146 patients were included (99 females and 47 males) with a mean age of 38±14 years. FC of more than 50 mg/kg was not significantly associated with clinically relevant capsule endoscopy findings (P=0.25), correlation coefficient was 0.11. Sensitivity, specificity, positive and negative predictive values for FC at a cut-off of more than 50 mg/kg were 88.9% [95% confidence interval (CI): 65.3-98.6], 25.0% (95% CI: 17.8-33.4), 14.3 (95% CI: 8.4-22.2) and 94.1% (95% CI: 80.3-99.3), respectively. A raised FC was not significantly associated with an elevated C-reactive protein or the presence of anaemia (P=0.19 and 0.10, respectively).

CONCLUSION

FC performs modestly as a screening test to exclude small bowel inflammation. However, we recommend interpretation within the overall clinical context to avoid overlooking the infrequent patient with small bowel inflammation and a negative FC.

Fecal calprotectin in the prediction of postoperative recurrence of Crohn's disease in children and adolescents

BACKGROUND

Fecal calprotectin (FC) correlates with endoscopic recurrence of Crohn's disease (CD) in adults but has not been studied among children postoperatively. We aimed to analyze whether FC relates with postoperative CD recurrence in children.

METHODS

Altogether 51 postoperative endoscopies and FC measurements from 22 patients having undergone surgery for CD at age ≤18years were included.

RESULTS

Ileocecal resection (n=15), small bowel resection (n=6), or left hemicolectomy (n=1) was performed at median age of 15.1 (interquartile range 14.4-17.6) years. Following surgery, FC decreased significantly (659 vs. 103μg/g, p=0.001). During median follow-up of 5.7 (4.2-7.7) years, either endoscopic or histological recurrence occurred in 17 patients (77%). FC >139μg/g at time of endoscopy or FC increase of 79μg/g compared to first postoperative value was suggestive of endoscopic recurrence (Rutgeerts score i2-i4), while FC >101μg/g or increase of 21μg/g indicated histological recurrence. Best accuracy for prediction of recurrence was obtained by combining FC at endoscopy and the postoperative increase of FC. The corresponding AUROC values were 0.74 (95% 0.58-0.89) for endoscopic recurrence whereas 0.81 (95% CI 0.67-0.95) for histological recurrence.

CONCLUSION

FC is a useful surrogate marker of postoperative recurrence also in pediatric CD patients.

Fecal Calprotectin for predicting Relapse and Activity in Patients with Crohn's Disease: A Meta-analysis

AIMS

We aimed to perform a meta-analysis of the predictive capacity of fecal calprotectin (FC) in activity and relapse of Crohn's disease (CD).

MATERIALS AND METHODS

MEDLINE, EMBASE, and the Cochrane Library databases were searched systematically. Pooled sensitivity, specificity, and other diagnostic indices were evaluated.

RESULTS

A total of 1,252 CD patients from 18 different studies were analyzed. The pooled sensitivity and specificity of FC at a cutoff value of 50 μg/g to predict activity of CD were 0.91 [95% confidence interval (CI): 0.87-0.95] and 0.47 (95% CI: 0.35-0.59) respectively. The pooled sensitivity and specificity of FC at a cutoff value of larger than 150 μg/g to monitor relapse of CD was 0.75 (95% CI: 0.67-0.82) and 0.71 (95% CI: 0.66-0.76) respectively. The area under the summary receiver operating characteristic (SROC) curve of FC for detecting CD activity was 0.78 (50 μg/g), 0.88 (100 μg/g), 0.85 (>150 μg/g), and the diagnostic odds ratio (DOR) was 10.21 (50 μg/g), 10.20 (100 μg/g), 11.68 (>150 μg/g) respectively.

CONCLUSION

As a simple and noninvasive marker, FC is useful to predict the activity and relapse in CD patients, and the capacity of FC to predict CD activity was superior to its application in monitoring relapse of CD.

HOW TO CITE THIS ARTICLE

Zhuge Y, Huang Q-P, Li Q, Wang J-S. Fecal Calprotectin for predicting Relapse and Activity in Patients with Crohn's Disease: A Meta-analysis. Euroasian J Hepato-Gastroenterol 2016;6(2):116-124.

Association Between Fecal Calprotectin Levels and Small-bowel Inflammation Score in Capsule Endoscopy: A Multicenter Retrospective Study

BACKGROUND

Accurate inflammation reporting in capsule endoscopy (CE) is important for diagnosis and monitoring of treatment of inflammatory bowel disease (IBD). Fecal calprotectin (FC) is a highly specific biomarker of gut inflammation. Lewis score (LS) was developed to standardize quantification of inflammation in small-bowel (SB) CE images.

GOALS

Multicenter retrospective study aiming to investigate correlation between LS and FC in a large group of patients undergoing CE for suspected or known small-bowel IBD, and to develop a model for prediction of CE results (LS) based on FC levels.

STUDY

Five academic centers and a district general hospital offering CE in UK, Finland, Sweden, Canada, and Israel. In total, 333 patients were recruited. They had small-bowel CE and FC done within 3 months.

RESULTS

Overall, correlation between FC and LS was weak (r s: 0.232, P < 0.001). When two clinically significant FC thresholds (100 and 250 μg/g) were examined, the r s between FC and LS was 0.247 (weak) and 0.337 (moderate), respectively (P = 0.307). For clinically significant (LS ≥ 135) or negative (LS < 135) for SB inflammation, ROC curves gave an optimum cutoff point of FC 76 μg/g with sensitivity 0.59 and specificity 0.41.

LIMITATIONS

Retrospective design.

CONCLUSIONS

LS appears to show low correlation with FC as well as other serology markers of inflammation. FC does not appear to be a reliable biomarker for significant small-bowel inflammation. Nevertheless, FC level ≥ 76 μg/g may be associated with appreciable visual inflammation on small-bowel CE in patients with negative prior diagnostic workup.

Endoscopic and Histological Findings Are Predicted by Fecal Calprotectin in Acute Intestinal Graft-Versus-Host-Disease

BACKGROUND

Gastrointestinal graft-versus-host-disease (GI-GVHD) is a major cause of nonrelapse mortality after hematopoietic stem cell transplantation (HSCT) necessitating endoscopic examinations and biopsies for diagnosis. Fecal calprotectin (CPT) has been widely used in gastrointestinal inflammation, but comprehensive data in GI-GVHD are lacking.

AIMS

We aimed to identify an association of CPT with endoscopic findings, mucosal damage and symptoms for diagnosing and monitoring acute GI-GVHD.

METHODS

Symptoms were prospectively evaluated in 110 consecutive HSCT recipients by standardized questionnaires and Bristol Stool Scale (BSS). CPT was assayed by ELISA. Symptom assessment and CPT were performed weekly and with onset of first symptoms. GVHD was diagnosed according to the Glucksberg criteria and by endoscopic biopsies. Patients with GI-GVHD received standard high-dose corticosteroid therapy and follow-up CPT, and symptom evaluation was performed after 28 days. Patients not responding to steroid treatment were re-evaluated by colonoscopy.

RESULTS

GI-GVHD was diagnosed in 40 patients. Twelve patients with GI symptoms and CMV colitis and 24 patients with isolated skin GVHD were included as control subjects. CPT was significantly higher in GI-GVHD compared to skin GVHD and CMV colitis. Endoscopic findings, histological grading, abdominal cramps, diarrhea, urgency and BSS correlated with CPT. At follow-up, CPT correlated with abdominal cramps, diarrhea, urgency and BSS. In steroid refractory patients, CPT level was still significantly associated with severity of mucosal damage.

CONCLUSION

CPT predicts endoscopic and histological findings in GI-GVHD and correlates with lower GI symptoms. It enables to discriminate GVHD from CMV colitis and to monitor therapeutic success.

Lewis Score--Prognostic Value in Patients with Isolated Small Bowel Crohn's Disease

BACKGROUND AND AIMS

Small bowel capsule endoscopy (SBCE) allows mapping of small bowel inflammation in Crohn's disease (CD). We aimed to assess the prognostic value of the severity of inflammatory lesions, quantified by the Lewis score (LS), in patients with isolated small bowel CD.

METHODS

A retrospective study was performed in which 53 patients with isolated small bowel CD were submitted to SBCE at the time of diagnosis. The Lewis score was calculated and patients had at least 12 months of follow-up after diagnosis. As adverse events we defined disease flare requiring systemic corticosteroid therapy, hospitalization and/or surgery during follow-up. We compared the incidence of adverse events in 2 patient subgroups, i.e. those with moderate or severe inflammatory activity (LS ≥790) and those with mild inflammatory activity (135 ≤ LS < 790).

RESULTS

The LS was ≥790 in 22 patients (41.5%), while 58.5% presented with LS between 135 and 790. Patients with a higher LS were more frequently smokers (p = 0.01), males (p = 0017) and under immunosuppressive therapy (p = 0.004). In multivariate analysis, moderate to severe disease at SBCE was independently associated with corticosteroid therapy during follow-up, with a relative risk (RR) of 5 (p = 0.011; 95% confidence interval [CI] 1.5-17.8), and for hospitalization, with an RR of 13.7 (p = 0 .028; 95% CI 1.3-141.9).

CONCLUSION

In patients with moderate to severe inflammatory activity there were higher prevalences of corticosteroid therapy demand and hospitalization during follow-up. Thus, stratifying the degree of small bowel inflammatory activity with SBCE and LS calculation at the time of diagnosis provided relevant prognostic value in patients with isolated small bowel CD.

Quantitative measurements in capsule endoscopy

This review summarizes several approaches for quantitative measurement in capsule endoscopy. Video capsule endoscopy (VCE) typically provides wireless imaging of small bowel. Currently, a variety of quantitative measurements are implemented in commercially available hardware/software. The majority is proprietary and hence undisclosed algorithms. Measurement of amount of luminal contamination allows calculating scores from whole VCE studies. Other scores express the severity of small bowel lesions in Crohn׳s disease or the degree of villous atrophy in celiac disease. Image processing with numerous algorithms of textural and color feature extraction is further in the research focuses for automated image analysis. These tools aim to select single images with relevant lesions as blood, ulcers, polyps and tumors or to omit images showing only luminal contamination. Analysis of motility pattern, size measurement and determination of capsule localization are additional topics. Non-visual wireless capsules transmitting data acquired with specific sensors from the gastrointestinal (GI) tract are available for clinical routine. This includes pH measurement in the esophagus for the diagnosis of acid gastro-esophageal reflux. A wireless motility capsule provides GI motility analysis on the basis of pH, pressure, and temperature measurement. Electromagnetically tracking of another motility capsule allows visualization of motility. However, measurement of substances by GI capsules is of great interest but still at an early stage of development.

Wireless capsule endoscopy of the small intestine in children

Wireless capsule endoscopy (CE) for the diagnosis of small-bowel disease has been in clinical use for more than a decade, and is no longer an emerging technology, but rather one that has reached fruition. This noninvasive technology has been readily embraced by both physicians and patients. Used in the diagnosis of inflammatory bowel disease, for locating sources of obscure gastrointestinal bleeding, and for assessing small-bowel polyp burden in polyposis syndromes as well as for less common indications, CE has transformed the diagnostic algorithms of small-bowel investigations. Although already in widespread use, the technology incorporated into the various CE platforms continues to improve and expand. Here, we briefly review the indications, limitations, and advances in video capsule technology, with an emphasis on its use in pediatrics.

Dissecting Lewis score under the light of fecal calprotectin; an analysis of correlation of score components with calprotectin levels in capsule endoscopy

BACKGROUND

Lewis Score (LS) is an inflammatory score in small-bowel capsule endoscopy (SBCE). Fecal calprotectin (FC) is considered the non-invasive, 'gold standard' marker of gastrointestinal (GI) inflammation. Recently, we reported that LS shows only a moderate correlation with FC. In this study, we aim to evaluate which LS parameters have greater correlation with FC.

METHODS

A retrospective, two-center study; 74 patients who underwent SBCE within 7 (median 1.5) days from a FC measurement. LS was calculated; univariate and multivariate analyses were performed, investigating LS correlation with FC, and which LS parameters had stronger correlation coefficient (rs) with FC.

RESULTS

74 patients had an FC measurement within 7 days of their SBCE examination (median 22 time-interval: 1.5 days; IQR: 5). Coefficient rs between LS and FC was moderate (0.454). In univariate analysis, the variables that gave the strongest association with FC were: the higher tertile subscore for ulcer, the summative ulcer subscore, the higher tertile ulcer score (only with descriptors of ulcer size and number), the summative ulcer score (only with descriptors of ulcer size and number), and subscores including various combinations of the stenosis descriptors. In multivariate analysis, the only positive predictor for FC was the higher tertile ulcer subscore (only with descriptors of ulcer size and number).

CONCLUSION

LS shows only moderate correlation to FC. This is due to a) an inherent limitation of LS, and b) the notion of correlating the 2 parameters, and consideration should be given to development of a new, simplified (or composite) inflammation score/index for SBCE.

Fecal calprotectin in patients with suspected small bowel disease--a selection tool for small bowel capsule endoscopy?

OBJECTIVE

Fecal calprotectin (FC) has been proposed as a selection tool for gastrointestinal examinations, but the use of FC in the diagnosis of small bowel disease in particular is less studied. The aim of this study was to assess if FC could be used to predict findings on small bowel capsule endoscopy (SBCE).

MATERIAL AND METHODS

We retrospectively collected FC values, SBCE findings and clinical data in 161 patients with suspected small bowel disease referred for SBCE. Findings on SBCE were correlated with FC levels and the diagnostic value of FC was assessed.

RESULTS

Of the 161 patients, 37.3% had a positive FC and 29.8% had a finding on SBCE. Overall there was a significant difference in FC values between patients with any finding on SBCE and patients with a normal SBCE, but patients with ulcers/erosions was the only subgroup of patients with FC values significantly higher than patients with a normal SBCE. The proportion of patients with findings on SBCE increased with increasing FC value. A positive FC (≥50 mg/kg) had a sensitivity, specificity, positive predictive value and negative predictive value of 54.2%, 69.9%, 43.3% and 78.2%, respectively, for predicting findings on SBCE.

CONCLUSIONS

FC alone cannot be used as a selection tool for SBCE in patients with suspected small bowel disease in a specialist setting. However, a high FC value implies a higher probability of finding significant pathology on SBCE, and thus strengthens the indication for performing the examination.