Monitoring of small bowel Crohn’s disease

Introduction: In recent years, the therapeutic paradigm in Crohn’s disease has shifted from a mere symptom-oriented approach, to aiming to healing of the underlying inflammation and prevention of long-term structural complications. Such ‘treat-to-target’ approach may allow for a more stable disease course with less hospitalizations, lower requirement for surgery and improved quality of life. In Crohn’s disease, the small bowel is affected in the majority of patients; frequently, Crohn’s involves only the small bowel, which remains inaccessible to conventional ileocolonoscopic techniques. Thus, non-invasive monitoring techniques are crucial for accurate disease assessment.

Areas covered: This review addresses the indications and clinical implications of non-invasive small bowel monitoring modalities (magnetic resonance enterography, intestinal ultrasound, capsule endoscopy) in the assessment and management of Crohn’s disease.

Expert commentary: This review addresses the limitations of the current knowledge and future areas of research, including the possible utilization of transmural healing as an imaging target and the need to establish clear quantitative target values to guide treatment by imaging findings in Crohn’s disease.     

Wireless capsule endoscopy and proximal small bowel lesions in Crohn’s disease

AIM: To investigate the prevalence of proximal small bowel (SB) lesions detected by wireless capsule endoscopy (WCE) in Crohn's disease (CD). METHODS: WCE was performed in 64 patients: 32 with CD of the distal ileum, and 32 controls with iron-deficiency anemia (IDA) or diarrhea. WCE was performed using the Given SB-WCE, followed by small intestine contrast ultrasonography (SICUS). Findings compatible with CD by using WCE included erosions, aphthoid or deep ulcers, and strictures/stenosis. RESULTS: WCE detec...     

Mesalamine for prophylaxis of small bowel Crohn’s disease recurrence

Mesalamine has been studied extensively as a therapeutic option in patients with Crohn’s disease. Endoscopic follow-up of patients resected for ileal Crohn’s disease has shown that, in the absence of treatment, postoperative recurrence occurs in approximately 70% to 90% of patients within 1 year of the operation. Recurrence requires further surgical intervention in approximately half of patients within 10 years. Therapeutic strategies aimed at preventing recurrence are essential to the management of patients with Crohn’s disease. This article offers a critical evaluation of results from clinical studies of mesalamine for prevention of recurrence in small bowel Crohn’s disease.     

Emergency and elective surgery for small bowel Crohn’s disease

Laparoscopic appendectomy was first performed more than 25 years ago. We performed a systematic literature search on laparoscopic appendectomy and selected related topics. The technique should be considered the gold standard for surgical removal of the appendix in women of childbearing age (level of evidence Ia). There is minor but consistent evidence that it should also be advocated for men (level of evidence III), obese (level of evidence III), and elderly (level of evidence IIb) patients, while there is some evidence of unfavorable results on pregnant women (level of evidence IIb). Studies reporting higher incidence of intra-abdominal abscesses after laparoscopic appendectomy are difficult to interpret due to a lack of standardization of the operative technique and lack of uniformity related to the different grades of disease (ranging from uninflamed appendix to diffuse peritonitis, gangrene, or perforation of the organ). As far as surgical technique, the three-port procedure is superior to needleoscopy and single port access (level of evidence Ia). Costly high-tech instruments for dissection are mostly unnecessary (level Ib). Mechanical closure of the stump might prove safer (level Ib). The quantity of peritoneal lavage fluid is generally scanty (level III), and abdominal drains are not useful (level Ia). Fast-track protocols should be implemented (level Ic). Training and technical standardization are the key to devising future trials on this topic.     

Structural bowel damage in quiescent Crohn’s disease

BackgroundCrohn’s disease is associated with accumulation of progressive structural bowel damage (SBD) leading to the development of stenotic and penetrating complications. The data pertaining to the course of progression of SBD is scarce. The Lemann index (LI) is a novel tool for evaluation of SBD that incorporates pan-enteric clinical, endoscopic and imaging data.AimsTo evaluate the progression of SBD in quiescent CD patients.MethodsPatients with known quiescent small bowel Crohn’s disease (CD) for at least 3 months (CDAI < 220) were prospectively recruited and underwent repeated magnetic resonance enterographies (MRE) and video capsule endoscopies (VCE). Patients were assessed for SBD on initial and follow-up evaluation using relevant clinicopathological data, MRE and VCE results. Significant structural bowel damage (SBD) was identified as LI > 4.8, and progression of SBD as LI > 0.3.ResultsSixty one patients were enrolled in the study. Significant SBD was detected 13 (21.4%) on enrollment. Duration of disease (p = 0.036) and history of CD-related surgery (p = 0.0001) were associated with significant BD. Forty one patients underwent a follow-up MRE (14.8 ± 2.5 months apart). LI was similar at baseline and follow-up. There was a negligible change in LI between the evaluations.ConclusionsIn patients with quiescent Crohn’s disease, structural bowel damage was stable over a median of 14 months follow-up.     

Capsule endoscopy in diagnosis of small bowel Crohn＇s disease

AIM: To evaluate the effectiveness of wireless capsule endoscopy in patients with suspected Crohn‘s disease (CD) of the small bowel undetected by conventional modalities,and to determine the diagnostic yield of M2A Given Capsule.METHODS: From May 2002 to April 2003, we prospectively examined 20 patients with suspected CD by capsule endoscopy. The patients had the following features:abdominal pain, weight loss, positive fecal occult blood test, iron deficiency anaemia, diarrhoea and fever. All the patients had normal results in small bowel series (SBS) and in upper and lower gastrointestinal endoscopy beforethey were examined. Mean duration of symptoms before diagnosis was 6.5 years.RESULTS: Of the 20 patients, 13 (65%) were diagnosed as CD of the small bowel according to the findings of M2A Given Capsule. The findings detected by the capsule were mucosal erosions (2 patients), aphthas (5 patients),nodularity (1 patient), large ulcers (2 patients), and ulcerated stenosis (3 patients). The distribution of the lesions was mainly in the distal part of the small bowel,and the mild degree of lesions was 54%.CONCLUSION: Wireless capsule endoscopy is effective in diagnosing patients with suspected CD undetected by conventional diagnostic methods. It can be used to detect early lesions in the small bowel of patients with CD.     

Imaging of the small bowel in Crohn＇s disease： A review of old and new techniques

The investigation of small bowel morphology is often mandatory in many patients with Crohn＇s disease. Traditional radiological techniques （small bowel enteroclysis and small bowel follow-through） have long been the only suitable methods for this purpose. In recent years, several alternative imaging techniques have been proposed. To review the most recent advances in imaging studies of the small bowel, with particular reference to their possible application in Crohn＇s disease, we conducted a complete review of the most important studies in which traditional and newer imaging methods were performed and compared in patients with Crohn＇s disease. Several radiological and endoscopic techniques are now available for the study of the small bowel; each of them is characterized by a distinct profile of favourable and unfavourable features. In some cases, they may also be used as complementary rather than alternative techniques. In everyday practice, the choice of the technique to be used stands upon its availability and a careful evaluation of diagnostic accuracy, clinical usefulness, safety and cost. The recent development of innovative imaging techniques has opened a new and exciting area in the exploration of the small bowel in Crohn＇s disease patients.     

Magnetic resonance evaluation for small bowel strictures in Crohn’s disease: comparison with balloon enteroscopy

Journal of Gastroenterology - Magnetic resonance (MR) imaging is the recommended technique for detection of small bowel lesions in Crohn’s disease. We aimed to evaluate the impact of...     

Diagnostic yield of capsule endoscopy versus magnetic resonance enterography and small bowel contrast ultrasound in the evaluation of small bowel Crohn’s disease: Systematic review and meta-analysis

Background and aimsCapsule endoscopy (CE), magnetic resonance enterography (MRE) and small bowel (SB) intestinal contrast ultrasound (SICUS) are the modalities of choice for SB evaluation. This study aimed to compare the diagnostic yield (DY) of CE to MRE and SICUS in detection and monitoring of SB CD through meta-analysis of the available literature.MethodsWe performed a systematic literature search for trials comparing the accuracy of CE, MRE and SICUS for detection of active SB inflammation in patients with suspected and/or established CD. Only prospective studies comparing CE with another additional diagnostic modality were included in the final analysis. Pooled odds ratios (ORs) for the DY of the three modalities were calculated.ResultsA total of 112 studies were retrieved; following selection, 13 studies were eligible for analysis. The DY of CE for detection of active SB CD was similar to that of MRE (10 studies, 400 patients, OR 1.17; 95% CI 0.83–1.67) and SICUS (5 studies, 142 patients, OR 0.88; 95% CI 0.51–1.53). The outcomes were similar for the subgroups of suspected versus established CD and adult versus pediatric patients. CE was superior to MRE for proximal SB CD (7 studies, 251 patients, OR 2.79; 95% CI 1.2–6.48); the difference vs SICUS was not significant.ConclusionCE, MRE and SICUS have similar DY for detection of SB CD in both suspected and established CD. CE is superior to MRE for detection of proximal SB disease, however the risk of capsule retention should be considered.     

Perianal Crohn’s disease – association with significant inflammatory activity in proximal small bowel segments

Objectives: Perianal Crohn’s disease (CD) prevalence varies according to the disease location, being particularly frequent in patients with colonic involvement. We aimed to evaluate small bowel involvement and compare small bowel capsule endoscopy findings and inflammatory activity between patients with and without perianal disease.

Materials and methods: Retrospective single-center study including 71 patients – all patients with perianal CD (17 patients) who performed a small bowel capsule endoscopy were included, and non-perianal CD patients were randomly selected (54 patients). Clinical and analytical variables at diagnosis were reviewed. Statistical analysis was performed with SPSS v21.0 and a two-tailed p value <.05 was defined as indicating statistical significance.

Results: Patients had a median age of 30?±?16 years with 52.1% females. Perianal disease was present in 23.9%. Patients with perianal disease had significantly more relevant findings (94.1% vs 66.6%, p?=?.03) and erosions (70.6% vs 42.6%, p?=?.04), however, no differences were found between the two groups regarding ulcer, villous edema and stenosis detection. Overall, patients with perianal disease had more frequently significant small bowel inflammatory activity, defined as a Lewis Score?≥135 (94.1% vs 64.8%, p?=?.03), and higher Lewis scores in the first and second tertiles (450?±?1129 vs 0?±?169, p?=?.02 and 675?±?1941 vs 0?±?478, p?=?.04, respectively). No differences were found between the two groups regarding third tertile inflammatory activity assessed with the Lewis Score.

Conclusion: Patients with perianal CD have significantly higher inflammatory activity in the small bowel, particularly in proximal small bowel segments, when compared with patients without perianal disease.     

Wireless capsule endoscopy and proximal small bowel lesions in Crohn��s disease

AIM: To investigate the prevalence of proximal small bowel (SB) lesions detected by wireless capsule endoscopy (WCE) in Crohn’s disease (CD).METHODS: WCE was performed in 64 patients: 32 with CD of the distal ileum, and 32 controls with iron-deficiency anemia (IDA) or diarrhea. WCE was performed using the Given SB-WCE, followed by small intestine contrast ultrasonography (SICUS). Findings compatible with CD by using WCE included erosions, aphthoid or deep ulcers, and strictures/stenosis.RESULTS: WCE detected proximal SB lesions in 16/32 (50%) patients (14 aphthoid ulcers, 2 deep ulcers, one stricture), which appeared not to be related to clinical parameters [epigastric pain, age, smoking, non-steroidal anti-inflammatory drugs (NSAIDs), IDA]. Among patients with proximal SB lesions, 6 (37%) were smokers, 3 (19%) NSAID users, 3 (19%) had epigastric pain and 4 (25%) had IDA. SICUS detected proximal SB lesions in 3/32 patients (19%) also showing lesions with WCE. No correlations were observed between proximal SB lesions assessed by WCE or by SICUS (χ² = 1.5, P = 0.2).CONCLUSION: The use of WCE allows the detection of previously unknown upper SB lesions in a high proportion of patients with a previous diagnosis of CD involving the distal ileum.     

A nationwide,multi-center,retrospective study of symptomatic small bowel stricture in patients with Crohn’s disease

Journal of Gastroenterology - Small bowel stricture is one of the most common complications in patients with Crohn’s disease (CD). Endoscopic balloon dilatation (EBD) is a minimally invasive...     

Crohn’s disease of the small intestine

Opinion statement  

Living with inflammatory bowel disease: A Crohn’s and Colitis Canada survey

BACKGROUND:

Despite improvements in therapies for inflammatory bowel diseases (IBDs), patient quality of life continues to be significantly impacted.

OBJECTIVE:

To assess the impact of IBD on patients and families with regard to leisure, relationships, mental well-being and financial security, and to evaluate the quality and availability of IBD information.

METHODS:

An online survey was advertised on the Crohn’s and Colitis Canada website, and at gastroenterology clinics at the University of Alberta Hospital (Edmonton, Alberta) and University of Calgary Hospital (Calgary, Alberta).

RESULTS:

The survey was completed by 281 IBD patients and 32 family members. Among respondents with IBD, 64% reported a significant or major impact on leisure activities, 52% a significant or major impact on interpersonal relationships, 40% a significant or major impact on financial security, and 28% a significant or major impact on planning to start a family. Patient information needs emphasized understanding disease progression (84%) and extraintestinal symptoms (82%). There was a strong interest in support systems such as health care insurance (70%) and alternative therapies (66%). The most common source of information for patients was their gastroenterologist (70%); however, most (70%) patients preferred to obtain their information from the Crohn’s and Colitis Canada website.

CONCLUSIONS:

The impact of IBD on interpersonal relationships and leisure activities was significant among IBD patients and their families. Understanding the disease, but also alternative treatment options, was of high interest. Currently, there is a discrepancy between interest in information topics and their availability. Respondents reported a strong desire to obtain information regarding disease progression, especially extraintestinal symptoms.     

Small bowel adenocarcinoma in Crohn＇s disease： A case report and review of literature

Small bowel adenocarcinomas are remarkable for their rarity, difficult diagnosis and poor prognosis. Here we report an unusual case of a 33-year-old patient in whom infiltrative adenocarcinoma of the small bowel was diagnosed after a 10-year history of Crohn's disease. In most previously reported cases, detection of Crohn's disease was subsequent to that of carcinoma of the small bowel or the patients involved had an even longer history of the disease. Our literature review suggests that the risk of small bowel adenocarcinoma is higher in patients with Crohn's disease than in the overall population. We present details on epidemiology as well as clinical and diagnostic aspects of this rare disease entity.     

Chronic intestinal failure and short bowel syndrome in Crohn’s disease

Chronic intestinal failure (CIF) is a rare but feared complication of Crohn’s disease. Depending on the remaining length of the small intestine, the affected intestinal segment, and the residual bowel function, CIF can result in a wide spectrum of symptoms, from single micronutrient malabsorption to complete intestinal failure. Management of CIF has improved significantly in recent years. Advances in home-based parenteral nutrition, in particular, have translated into increased survival and improved quality of life. Nevertheless, 60% of patients are permanently reliant on parenteral nutrition. Encouraging results with new drugs such as teduglutide have added a new dimension to CIF therapy. The outcomes of patients with CIF could be greatly improved by more effective prevention, understanding, and treatment. In complex cases, the care of patients with CIF requires a multidisciplinary approach involving not only physicians but also dietitians and nurses to provide optimal intestinal rehabilitation, nutritional support, and an improved quality of life. Here, we summarize current literature on CIF and short bowel syndrome, encompassing epidemiology, pathophysiology, and advances in surgical and medical management, and elucidate advances in the understanding and therapy of CIF-related complications such as catheter-related bloodstream infections and intestinal failure-associated liver disease.     

Effect of infliximab on small bowel stenoses in patients with Crohn＇s disease

AIM： To assess prospectively small bowel stenoses in Crohn＇s disease （CD） patients treated with infliximab using Small Intestine Contrast Ultrasonography （SICUS）. METHODS： Twenty patients （M 12, age, 42.7 ± 11.8 years）, 15 of whom showed obstructive symptoms indicating the presence of small bowel stenosis, and 5 without stenosis, were treated with infliximab （5 mg/kg at wk 0, 2, 6 and 5 mg/kg every 8 wk thereafter） for steroid refractoriness, fistulizing disease, or to avoid high-risk surgery. SICUS was performed at the induction phase and at regular time intervals during the followup period of 34.7 ± 16.1 mo （range 7-58）. Small bowel stenoses were detected by SICUS, endoscopy and MRI. RESULTS： In no case was progression of stenoses or the appearance of new ones seen. Of the 15 patients with stenosis, 5 stopped treatment after the induction phase （2 for no response, 3 for drug intolerance, one of whom showed complete regression of one stenosis）. Among the remaining 10 patients, a complete regression of 8 stenoses （1 stenosis in 5 patients and 3 stenoses in one patient） was observed after 6-22 infliximab infusions. CONCLUSION： In patients with CD treated with infliximab we observed： （a） No progression of small bowel stenosis and no appearance of new ones, （b） Complete regression of 1/22 stenosis after the induction phase and of 8/15 （53.3%） stenosis after 6-22 infusions during maintenance therapy.     

Management of perianal fistulas in Crohn’s disease:An upto-date review

Perianal disease is one of the most disabling manifestations of Crohn’s disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagnosis,based on endoscopy,magnetic resonance imaging,endoanal ultrasound and examination under anesthesia,is crucial for perianal fistula treatment.Available medical and surgical therapies are discussedin this review,including new local treatment modalities that are under investigation.     

Aspecific ileitis: Crohn’s disease or not Crohn’s disease? A prospective study

Purpose

It is not clear whether aspecific ileitis may represent an early manifestation or a milder variant of Crohn’s disease or not. The aim of this study was to evaluate the clinical outcomes of aspecific ileitis.

Methods

Subjects with at least one of the following signs at retrograde ileoscopy: erythema, nodularity, aftae, erosions, and ulcers were considered. They should not have had defined gastrointestinal disease, biochemical signs of inflammation, use of drugs, celiac disease, and intestinal infectious disease.

Results

We enrolled 51 subjects (22 men), mean age (± SD) at colonoscopy of 41.1 ± 13.1 years. Indications to colonoscopy were overt or occult intestinal bleeding (18), diarrhoea (15), systemic signs (10), IBS-like symptoms (5), other (3). Ileal lesions were ulcers (9), erosions (26), aftae (10), nodularity (3), and erythema (3). At histological evaluation aspecific findings were observed. Forty-four out of 51 (86.3%) subjects underwent further investigations of small bowel. Second colonoscopy was performed in 31 (60.8%) persisting symptomatic subjects: ileitis was confirmed in 14 (46.6%). Ten out of 51 (19.6%) were eventually diagnosed as affected by Crohn’s disease.

Conclusions

A substantial proportion of subjects with endoscopic and histological findings of aspecific ileitis is eventually diagnosed as affected by Crohn’s disease. In these subjects, a strict follow-up is strongly recommended.