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...     

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.     

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.     

Enteroscopy in small bowel Crohn’s disease: A review

Crohn’s disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in inflammation, stricturing and fistulae secondary to transmural inflammation. Diagnosis relies on clinical history, abnormal laboratory parameters, characteristic radiologic and endoscopic changes within the gastrointestinal tract and most importantly a supportive histology. The article is intended mainly for the general gastroenterologist and for other interested physicians. Management of small bowel CD has been suboptimal and limited due to the inaccessibility of the small bowel. Enteroscopy has had a significant renaissance recently, thereby extending the reach of the endoscopist, aiding diagnosis and enabling therapeutic interventions in the small bowel. Radiologic imaging is used as the first line modality to visualise the small bowel. If the clinical suspicion is high, wireless capsule endoscopy (WCE) is used to rule out superficial and early disease, despite the above investigations being normal. This is followed by push enteroscopy or device assisted enteroscopy (DAE) as is appropriate. This approach has been found to be the most cost effective and least invasive. DAE includes balloon-assisted enteroscopy, [double balloon enteroscopy (DBE), single balloon enteroscopy (SBE) and more recently spiral enteroscopy (SE)]. This review is not going to cover the various other indications of enteroscopy, radiological small bowel investigations nor WCE and limited only to enteroscopy in small bowel Crohn’s. These excluded topics already have comprehensive reviews. Evidence available from randomized controlled trials comparing the various modalities is limited and at best regarded as Grade C or D (based on expert opinion). The evidence suggests that all three DAE modalities have comparable insertion depths, diagnostic and therapeutic efficacies and complication rates, though most favour DBE due to higher rates of total enteroscopy. SE is quicker than DBE, but lower complete enteroscopy rates. SBE has quicker procedural times and is evolving but the least available DAE today. Larger prospective randomised controlled trial’s in the future could help us understand some unanswered areas including the role of BAE in small bowel screening and comparative studies between the main types of enteroscopy in small bowel CD.     

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.     

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...     

Crohn’s disease of the small intestine

Opinion statement  

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.     

Objective evaluation for treat to target in Crohn’s disease

Journal of Gastroenterology - Crohn’s disease (CD) is a chronic and destructive bowel disease; continued disease activity can lead to penetrating complications. With the recent advent of...     

Capsule enteroscopy is useful for the therapeutic management of Crohn’s disease

AIM: To analyze therapeutic changes in Crohn’s disease (CD) patients following video capsule endoscopy (VCE) and to assess the usefulness of Lewis score and the Patency Capsule.METHODS: Patency Capsule was performed in every patient that had indication for VCE, and those with negative patency did not undergo VCE. Patients with established CD that underwent VCE between January 2011 and February 2014 were selected for this study; those with suspected CD were excluded, independent of VCE results, since our purpose was to address differences in therapeutic regimen in CD patients before and after VCE. Patients with inconclusive VCE were also excluded. Patients had to be free of non-steroidal anti-inflammatories for at least 1 mo. Those patients who met these criteria were allocated into one of three groups: Staging group (asymptomatic CD patients that underwent VCE for staging of CD), Flare group (patients with active CD), or Post-op group (CD patients evaluated for post-operative recurrence). Lewis score was calculated for every VCE procedure. Statistical analysis was performed to address the impact of VCE findings on the therapeutic management of CD patients and to evaluate the utility of the Lewis score.RESULTS: From a total of 542 VCEs, 135 were performed in patients with CD. Patency capsule excluded nearly 25% of the patients who were supposed to undergo VCE. No videocapsule retention during VCE was reported. From these 135 patients, 29 were excluded because CD diagnosis was not established at the time of VCE. Therefore, a total of 106 patients were included in the final analysis. From these, the majority were in the Staging group (n = 73, 69%), and the remaining were in the Flare (n = 23, 22%) or Post-op (n = 10, 9%) group. Median time between diagnosis and VCE was 5.5 years. Overall, VCE determined changes in the treatment of 40% of patients: only 21% remained free of immunosuppressors after VCE compared to 44% before VCE (P < 0.001). The differences in therapy before and after VCE achieved statistical significance in the Staging and Flare groups. In addition, patients were significantly different when stratified regarding time since diagnosis to the date of VCE. A higher Lewis score was associated with therapeutic modifications (P < 0.0001); where a score higher than 1354 was related to 90% probability of changing therapy [area under the receiver operative characteristic (AUROC) 0.80 (95%CI: 0.69-0.88)].CONCLUSION: VCE significantly changed the therapeutic management of CD patients, even in those with long-term disease. Systematic use of Patency capsule allowed for no videocapsule retention.     

The use of single balloon enteroscopy in Crohn’s disease and its impact on clinical outcome

Objectives: Single balloon enteroscopy (SBE) is an effective and safe modality for the diagnosis and therapeutic intervention of small bowel disorders. Its use in patients with Crohn’s disease (CD) and particularly its effect on management changes in CD have not yet been determined.

Materials and methods: We performed a retrospective review of the endoscopic and clinical data available on a cohort of patients with small bowel CD who had undergone SBE to determine the diagnostic and therapeutic yield of the procedure and the initial and longer-term impact it had on clinical management.

Results: About 52 patients have undergone SBE in our unit for the investigation of known (n?=?39) or suspected (n?=?13) small bowel CD with a diagnostic yield of 77% and 39%, respectively. SBE had an immediate clinical impact in 69% (n?=?33) of patients, including dilatation of a stricture in 27% (n?=?13), initiation or adjustment of dose of medications in 48% (n?=?23), referral for surgical resection in 6% (n?=?3). Moreover, the procedure permitted determining a new diagnosis of CD in 8% of the patients (n?=?4), and excluding it in 8% (n?=?4). Longer term follow-up was available in 34 patients (65%) which showed a significant difference in mean HBI score from 6.6 before the procedure to 4.2 after it (p?Conclusions: SBE has a high diagnostic and therapeutic yield in CD and significantly impacts disease management. Careful patient selection is a key factor in optimizing its use in CD.     

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.     

The advances and application of enteroscopy for small bowel

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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.     

Perianal disease is associated with psychiatric co-morbidity in Crohn’s disease in remission

Background and aim

Crohn’s disease is a life-long inflammatory disease which can impair quality of life, in particular in patients with psychiatric co-morbidities such as depression and anxiety. The aim of this prospective cohort study was to assess the prevalence of depression and anxiety and related risk factors in patients with quiescent Crohn’s disease.

Methods

A consecutive series of adult patients with confirmed diagnosis of Crohn’s disease, in clinical remission, were included and investigated during ambulatory visits using a standard questionnaire assessing demographic and clinical features of the disease. Within 1 month after the ambulatory visit, all patients were interviewed by phone to assess the presence of psychiatric disorders using standardized questionnaires. The questionnaire assessed the development of psychiatric disorders after the diagnosis of Crohn’s disease, the use of antidepressant or antianxiety therapy and current anxiety or depression by means of the Hospital Anxiety and Depression Scale.

Results

One hundred and ninety-five patients were included. Seventy-two (36.9 %) patients showed anxiety and/or depression symptoms, 46 (23.6 %) patients showed anxiety symptoms, 6 (3.1 %) patients showed depression symptoms and 20 (10.3 %) patients showed both symptoms. Forty-eight of these patients (58 %) were without any antidepressive or antianxiety treatment. Anxiety with or without depression was significantly correlated with female sex (p?=?0.017), history of perianal disease (p?=?0.003) and perianal surgery (p?=?0.042).

Conclusion

Anxiety is a frequent, often untreated, condition in patient affected by Crohn’s disease in clinical remission. Female sex, history of perianal disease and perianal surgery are major risk factors for anxiety.     

Predictors of early recurrence after strictureplasty for Crohn’s disease of the small bowel during the years of biologics

BackgroundThe identification of patients prone to early recurrence of Crohn’s disease at the site of a strictureplasty is fundamental in the clinical practice.AimsAim of the study is to detect the risk factors for early reoperation for recurrence after primary strictureplasty.MethodsFrom 2000, patients undergoing a primary strictureplasty and a subsequent reoperation for recurrence of Crohn’s disease at the site of a strictureplasty were included. Univariate and multivariable linear regression models were performed to analyse the relationship between the time to recurrence and independent variables.ResultsFifty-nine patients were included. Median time to recurrence was 4.5 years (0.7–12.6). At the multivariate linear regression, early relapse was significantly associated with use of biologics before primary surgery (?2.69, p < 0.0001) and location of disease in the ileum (?1.61, p 0.017). The use of biologics after surgery was similar between groups (40.7 vs 37.5%, p 0.79).ConclusionsThe location of Crohn’s disease in the ileum and the use of biologics before surgery are strong predictors of early site-specific recurrence after strictureplasty. In this group of patients, a tailored follow-up and aggressive postoperative treatment should be considered.     

A case of small bowel adenocarcinoma in a patient with Crohn＇s disease detected by PET/CT and double-balloon enteroscopy

Small bowel adenocarcinoma （SBA） in patients with Crohn＇s disease （CD） is quite rare, difficult to diagnose without surgery, and has a poor prognosis. Here, we report a 48-year-old man with SBA and a 21-year history of CD who was diagnosed by a combination of positron emission tomography/computed tomography （PET/CT） and double-balloon enteroscopy （DBE）. Since the age of 27 years, the patient had been treated for ileal CD and was referred to our hospital with persistent melena. Multiple hepatic tumors were found by CT. PET/CT detected an accumulation spot in the small bowel. DBE revealed an ulcerative tumor in the ileum about 100 cm from the ileocecal valve. An endoscopic forceps biopsy specimen showed poorly differentiated adenocarcinoma. There were some longitudinal ulcer scars near the tumor, and the chronic inflammation in the small bowel appeared to be associated with the cancer development. Previous reports suggest the risk of SBA in patients with CD is higher than in the overall population. Since early diagnosis is extremely difficult in these cases, novel techniques, such as PET/CT and DBE, may be expected to help in making a preoperative diagnosis of the development of SBA in CD.