Current role of capsule endoscopy in Crohn's disease

Capsule endoscopy(CE) currently plays an important role in Crohn's disease(CD). It is a noninvasive technique that has led to a breakthrough in the endoscopic diagnosis of diseases of the small intestine. Its superior diagnostic performance and excellent safety profile lead to its considerable acceptance on the part of the patient. This paper reviews current indications of CE in three stages of clinical practice: Suspected CD, unclassified colitis and its extensive role in diagnosed CD. The diagnostic and therapeutic impact of the results of CE on the monitoring of this disease is also reviewed. Knowledge of its applications, the interpretation of its results in an appropriate context and the existence of a validated endoscopic activity index could change the way in which these patients are managed. The definition of mucosal healing and postoperative recurrence by means of endoscopic scoring systems will endow CE with new applications in the management of CD in the near future.     

Capsule endoscopy:Present status and future expectation

Video capsule endoscopy(CE)since its introduction 13years back,has revolutionized our approach to small intestinal diseases.Obscure gastrointestinal bleed(OGIB)continues to be the most important indication for CE with a high sensitivity,specificity as well as positive and negative predictive values.It is best performed during ongoing bleed or immediately thereafter.Overt OGIB has a higher diagnostic yield than occult OGIB.However,even in iron deficiency anemia,CE is emerging as important investigation after initial negative work up.In suspected Crohn’s disease(CD),CE has been shown superior to traditional imaging and endoscopic technique and should be considered after a negative ileocolonoscopy.Although CE has also been used for evaluating established CD,a high capsule retention rate precludes its use ahead of cross-sectional imaging.Celiac disease,particularly where gastro-duodenoscopy cannot be performed or is normal,can also be investigated by CE.Small bowel tumor,hereditary polyposis syndrome,and non-steroidal anti-inflammatory drugs induced intestinal damage are other indications for CE.Capsule retention is the only significant adverse outcome of CE and occurs mostly in presence of intestinal obstruction.This can be prevented by use of Patency capsule prior to CE examination.Presence of cardiac pacemaker and intracardiac devices continue to be relative contraindications for CE,though data do not suggest interference of CE with these devices.Major limitations of CE today include failure to control its movement from outside,inability of CE to acquire tissue for diagnosis,and lack of therapeutic help.With ongoing interesting and exciting developments taking place in these areas,these issues would be solved in all probability in near future.CE has the potential to become one of the most important tools in diagnostic and possibly in the therapeutic field of gastrointestinal disorder.     

Small bowel video capsule endoscopy in Crohn’s disease: What have we learned in the last ten years?

Since its introduction in 2001, capsule endoscopy (CE) has become the most important advance in the study of small bowel disease, including Crohn’s disease (CD). This technique has been demonstrated to be superior to all other current forms of radiological investigation in detecting mucosal abnormalities of small bowel nonstricturing CD. CE has proven to be extremely useful in diagnosing CD in patients with inconclusive findings from ileocolonoscopy and x-ray-based studies. Almost half of all patients with CD involving the ileum also present lesions in proximal intestinal segments, with the small bowel being exclusively involved in up to 30% of all CD cases. Despite the widespread use of CE, several questions concerning the utility of this technique remain unanswered. The lack of commonly agreed diagnostic criteria for defining CD lesions with the aid of CE may have had an influence on the variation in diagnostic re sults for CE reported in the literature. The utility of CE in monitoring CD and in guiding therapy has also been proposed. Furthermore, CE could be a useful second-line technique for patients with an established diagn osis of CD and unexplained symptoms. Finally, as no thres hold for CD diagnosis has been agreed upon, a se verity scale of mucosal disease activity has notbeen universally followed. None of the available activity indexes based on CE findings has been independently validated. This article discusses several cutting-edge aspects of the usefulness of CE in CD 10 years after its introduction as a sensible method to study the small intestine.     

Role of wireless capsule endoscopy in inflammatory bowel disease

Capsule endoscopy (CE) offers state-of-the-art imaging of the small bowel. In Crohn's disease its clinical role is still uncertain. This report analyses the usefulness of CE in patients with suspected Cronh's disease, in patients with established Crohn's disease (when assessing severity, occult gastrointestinal bleeding and/or as a guide to therapy), in patients with inflammatory bowel disease unclassified (IBDU), and in individuals with ulcerative colitis. The first item in this group is the most important although there is no strong evidence to establish the position of CE in the diagnostic workup. In patients with established Crohn's disease, recently developed activity scores are promising tools for an accurate assessment of severity. As a guide to therapy, CE should be focused on patients with unexplained symptoms when other investigations are inconclusive. In postoperative Crohn's Disease, international consensus recommended considering CE only if ileocolonoscopy is contraindicated or unsuccessful. In the case of IBDU, studies have shown a significant proportion of patients reclassified with Crohn's disease. In this setting, CE could have a role determining small bowel involvement. The role of CE in ulcerative colitis is limited. Some authors advocate CE before colectomy for refractory cases in order to exclude Crohn's disease. In summary, CE offers a new horizon in inflammatory bowel disease, and a better knowledge of mucosal abnormalities that could offer a paradigm shift: changing from symptom-based disease activity estimation to direct mucosal healing monitoring. Nevertheless, randomized controlled studies are still needed to provide stronger evidence in this setting.     

Capsule endoscopy in suspected small bowel Crohn＇s disease： Economic impact of disease diagnosis and treatment

AIM: To model clinical and economic benefits of capsule endoscopy (CE) compared to ileo-colonoscopy and small bowel follow-through (SBFT) for evaluation of suspected Crohn’s disease (CD).METHODS: Using decision analytic modeling, total and yearly costs of diagnostic work-up for suspected CD were calculated, including procedure-related adverse events, hospitalizations, office visits, and medications. The model compared CE to SBFT following ileo-colonoscopy and secondarily compared CE to SBFT for initial evaluation.RESULTS: Aggregate charges for newly diagnosed, medically managed patients are approximately $8295. Patients requiring aggressive medical management costs are $29 508; requiring hospitalization, $49 074. At sensitivity > 98.7% and specificity of > 86.4%, CE is less costly than SBFT.CONCLUSION: Costs of CE for diagnostic evaluation of suspected CD is comparable to SBFT and may be used immediately following ileo-colonoscopy.     

Prospective postsurgical capsuleendoscopyin patients with Crohn’s disease简

AIM: To clarify the usefulness of postsurgical capsule endoscopy (CE) in the diagnosis of recurrent small bowel lesions of Crohn’s disease (CD).METHODS: This prospective study included 19 patients who underwent ileocolectomy or partial ileal resection for CD. CE was performed 2-3 wk after surgery to check for the presence/absence and severity of lesions remaining in the small bowel, and for any recurrence at the anastomosed area. CE was repeated 6-8 mo after surgery and the findings were compared with those obtained shortly after surgery. The Lewis score (LS) was used to evaluate any inflammatory changes of the small bowel.RESULTS: One patient was excluded from analysis because of insufficient endoscopy data at the initial CE. The total LS shortly after surgery was 428.3 on average (median, 174; range, 8-4264), and was ≥ 135 (active stage) in 78% (14 of 18) of the patients. When the remaining unresected small bowel was divided into 3 equal portions according to the transition time (proximal, middle, and distal tertiles), the mean LS was 286.6, 83.0, and 146.7, respectively, without any significant difference. Ulcerous lesions in the anastomosed area were observed in 83% of all patients. In 38% of the 13 patients who could undergo CE again after 6-8 mo, the total LS was higher by ≥ 100 than that recorded shortly after surgery, thus indicating a diagnosis of endoscopic progressive recurrence.CONCLUSION: Our pilot study suggests that CE can be used to objectively evaluate the postoperative recurrence of small bowel lesions after surgery for CD.     

Endoscopic ultrasonography-guided trucut biopsy for the preoperative diagnosis of peripancreatic castleman＇s disease： A case report

Castleman＇s disease （CD） of the pancreas/peripancreas is extremely rare. The recently introduced, endoscopic ultrasonography （EUS）-guided trucut biopsy （TCB） is a useful diagnostic rnodality for obtaining tissue samples from peripancreatic lesions. However, its role in diagnosing CD remains unknown. We report a case of localized, peripancreatic, hyaline-vascular CD biopsied using EUS. The pathology results were initially interpreted as an extranodal, marginal-zone B-cell lyrnphoma. However, polyrnerase chain reaction （PCR） study for the IgH gene rearrangement revealed a polyclonal pattern. We also reviewed the relevant literature. To our knowledge, this is the first illustrated report on EUS-TCB findings of CD with its pathology results of EUS-TCB mimicked a B-cell lymphoma.     

一种小肠克罗恩病胶囊内镜诊断标准的应用价值初探

目的探讨一种小肠克罗恩病的胶囊内镜诊断标准的应用价值。方法选择2003年3月至2008年10月因临床可疑小肠克罗恩病行胶囊内镜检查患者,根据DeBona等小肠克罗恩病胶囊内镜诊断标准进行诊断并分组,对所有患者进行电话随访1～5年,评价该标准的临床应用价值。结果最终共50例患者纳入研究,分为3组。A组25例患者确诊为小肠克罗恩病,有3例接受手术治疗,病理证实为克罗恩病,其余药物治疗均好转;B组15例临床拟诊小肠克罗恩病,均按克罗恩病进行试验性治疗,2例疗效欠佳,行手术治疗,证实是小肠憩室,另外13例患者症状明显好转;C组诊断为非特异性小肠炎,给予甲硝唑及培菲康治疗至少3个月以上。以上3组患者均随访1～5年无复发。结论该种小肠克罗恩病胶囊内镜诊断标准使早期诊断小肠克罗恩病成为可能,并可指导临床早期治疗。     

Five years' experience with capsule endoscopy in a single Center

Capsule endoscopy (CE) is a novel technology that facilitates highly effective and noninvasive imaging of the small bowel. Although its efficacy in the evaluation of obscure gastrointestinal bleeding (OGIB) has been proven in several trials, data on uses of CE in different small bowel diseases are rapidly accumulating in the literature, and it has been found to be superior to alternative diagnostic tools in a range of such diseases.Based on literature evidence, CE is recommended as a first-line investigation for OGIB after negative bidirectional endoscopy. CE has gained an important role in the diagnosis and follow-up of Crohn's disease and celiac disease and in the surveillance of small bowel tumors and polyps in selected patients. Capsule retention is the major complication, with a frequency of 1%-2%. The purpose of this review was to discuss the procedure, indications, contraindications and adverse effects associated with CE. We also review and share our five-year experience with CE in various small bowel diseases. The recently developed balloon-assisted enteroscopies have both diagnostic and therapeutic capability. At the present time, CE and balloon-assisted enteroscopies are complementary techniques in the diagnosis and management of small bowel diseases.     

Novel biomarkers of fibrosis in Crohn’s disease

Fibrosis represents a major challenge in Crohn’s disease (CD), and many CD patients will develop fibrotic strictures requiring treatment throughout their lifetime. There is no drug that can reverse intestinal fibrosis, and so endoscopic balloon dilatation and surgery are the only effective treatments. Since patients may need repeated treatments, it is important to obtain the diagnosis at an early stage before strictures become symptomatic with extensive fibrosis. Several markers of fibrosis have been proposed, but most need further validation. Biomarkers can be measured either in biological samples obtained from the serum or bowel of CD patients, or using imaging tools and tests. The ideal tool should be easily obtained, cost-effective, and reliable. Even more challenging is fibrosis occurring in ulcerative colitis. Despite the important burden of intestinal fibrosis, including its detrimental effect on outcomes and quality of life in CD patients, it has received less attention than fibrosis occurring in other organs. A common mechanism that acts via a specific signaling pathway could underlie both intestinal fibrosis and cancer. A comprehensive overview of recently introduced biomarkers of fibrosis in CD is presented, along with a discussion of the controversial areas remaining in this field.     

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.     

Capsule endoscopy in Crohn’s disease: Are we seeing any better?

Crohn’s disease (CD) is a complex, immune-mediated disorder that often requires a multi-modality approach for optimal diagnosis and management. While traditional methods include ileocolonoscopy and radiologic modalities, increasingly, capsule endoscopy (CE) has been incorporated into the algorithm for both the diagnosis and monitoring of CD. Multiple studies have examined the utility of this emerging technology in the management of CD, and have compared it to other available modalities. CE offers a noninvasive approach to evaluate areas of the small bowel that are difficult to reach with traditional endoscopy. Furthermore, CE maybe favored in specific sub segments of patients with inflammatory bowel disease (IBD), such as those with IBD unclassified (IBD-U), pediatric patients and patients with CD who have previously undergone surgery.     

Five years＇experience with capsule endoscopy in a single center

Capsule endoscopy （CE） is a novel technology that facilitates highly effective and noninvasive imaging of the small bowel. Although its efficacy in the evaluation of obscure gastrointestinal bleeding （OGIB） has been proven in several trials, data on uses of CE in different small bowel diseases are rapidly accumulating in the literature, and it has been found to be superior to alternative diagnostic tools in a range of such diseases. Based on literature evidence, CE is recommended as a first-line investigation for OGIB after negative bidirectional endoscopy. CE has gained an important role in the diagnosis and follow-up of Crohn＇s disease and celiac disease and in the surveillance of small bowel tumors and polyps in selected patients. Capsule retention is the major complication, with a frequency of 1%-2%. The purpose of this review was to discuss the procedure, indications, contraindications and adverse effects associated with CE. We also review and share our five-year experience with CE in various small bowel diseases. The recently developed balloon-assisted enteroscopies have both diagnostic and therapeutic capability. At the present time, CE and balloon-assisted enteroscopies are complementary techniques in the diagnosis and management of small bowel diseases.     

Advances in the Diagnosis and Management of Inflammatory Bowel Disease: Challenges and Uncertainties

Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn''s Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990–2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.     

胶囊内镜、CT小肠成像、小肠造影及回结肠镜对克罗恩病诊断价值的比较

目的 比较4种影像技术方法在小肠克罗恩病(CD)诊断中的应用价值.方法 57例经临床病理诊断为小肠CD的患者伴有不同程度腹痛、消瘦、腹泻或发热、大便潜血阳性等症状体征,进行回结肠镜、CT小肠成像(CTE)、胶囊内镜(CE)、小肠造影(SBFT)检查,发现异常患者则具体记录病变部位、性质,并对单项检杳及两项检查联合的阳性检出率进行比较.结果 57例CD患者中50例完成了回结肠镜检查,33例发现回肠末端溃疡(66.00%),17例回肠末端正常;CTE 34例,发现小肠病变29例(85.29%);CE 27例,其中1例发生CE在胃内潴留未达小肠,发现小肠病变26例(96.30%);SBFT 39例,发现小肠病变26例(66.67%).CE诊断CD的阳性率最高(96.30%),而回结肠镜最低(66.0%),4种检查方法的阳性率差异有统计学意义(P=0.006).两种检查方法联合的诊断CD的阳性检出率:CE+CTE为92.86%(13/14),SBFT+CTE为90.91%(20/22),CE+回结肠镜为95.65%(22/23),CE+SBFT为100%(17/17),回结肠镜+CTE为89.66%(26/29),回结肠镜+SBFT为77.78%(28/36),两种检查联合的组间比较,差异无统计学意义(P=0.140).结论 CE、CTE诊断轻度、中度CD的阳性率比SBFT高,CE发现早期黏膜病变较好,CTE发现肠壁及肠外病变较好,最重要的是CE及CTE可应用于非梗阻性小肠CD患者,传统技术如SBFT或回结肠镜阴性或不能明确诊断时,CE还可用于解释临床症状、随访及指导治疗.     

Capsule endoscopy in Crohn's disease — Indications and reservations 2008

Capsule endoscopy (CE) was found to be an effective tool in diagnosis of small bowel pathology. This review will focus on its role in Crohn's disease. Its role in patients with suspected Crohn's disease (CD) is described. CE has an established role for diagnosing CD when other tests are negative, though it is not a first line investigative tool in these patients. Over diagnosis is of concern. Its use in established CD remains an open question. It can provide exact mapping of small bowel disease before surgery, and might have impact on the treatment of the disease. It may have role in monitoring mucosal healing, which is becoming a target of therapy, and may help establish the exact diagnosis in a limited group of patients with indeterminate colitis. Retention of CE might occur. It is of low rate in patients with suspected CD and higher in patients with known CD but clinical obstruction is extremely rare. Economic considerations are a limit to a wider application of the CE.     

Colon capsule endoscopy for inflammatory bowel disease

Colon capsule endoscopy (CCE) is designed for direct visualization of the colonic mucosa through passive propulsion. The role of CCE in the detection of colonic polyps has been extensively evaluated. As mucosal healing has emerged as a pivotal target for treatment of inflammatory bowel disease (IBD), there is increasing data to suggest that CCE can also be used in the monitoring of mucosal inflammation in patients with active IBD, particularly in ulcerative colitis (UC) and Crohn's disease (CD). Despite advantages such as its non‐invasive nature, patient's comfort, safety, and access to anatomical regions not easily reached by conventional endoscopy, CE has limitations including the lack of ability to obtain biopsies or therapeutic capabilities and no control over movement. In this review, the role and diagnostic value of CCE on diagnosis and monitoring of UC and CD patients, its safety and limitations are discussed.     

Differences in clinical features of Crohn’s disease and intestinal tuberculosis

AIM: To investigate the clinical features of Crohn’s disease(CD) and intestinal tuberculosis(ITB) with a scoring system that we have developed.METHODS: A total of 25 CD and 40 ITB patients were prospectively enrolled from August 2011 to July 2012.Their characteristics and clinical features were recorded. Laboratory, endoscopic, histologic and radiographic features were determined. The features with a high specificity were selected to establish a scoring system. The features supporting CD scored +1, and those supporting ITB scored-1; each patient received a final total score. A receiver operating characteristic(ROC) curve was used to determine the best cut-off value for distinguishing CD from ITB.RESULTS: Based on a high specificity of differentiating between CD and ITB, 12 features, including longitudinal ulcers, nodular hyperplasia, cobblestone-like mucosa, intestinal diseases, intestinal fistula, the target sign, the comb sign, night sweats, the purified protein derivative test, the interferon-γ release assay(T-SPOT.TB), ring ulcers and ulcer scars, were selected for the scoring system. The results showed that the average total score of the CD group was 3.12 ± 1.740, the average total score of the ITB group was-2.58 ± 0.984, the best cutoff value for the ROC curve was-0.5, and the diagnostic area under the curve was 0.997, which was statistically significant(P < 0.001). The patients whose total scores were higher than-0.5 were diagnosed with CD; otherwise, patients were diagnosed with ITB. Overall, the diagnostic accuracy rate and misdiagnosis rate of this scoring system were 97% and 3%, respectively. CONCLUSION: Some clinical features are valuable for CD and ITB diagnosis. The described scoring system is key to differentiating between CD and ITB.     

Capsule endoscopy in suspected small bowel Crohn's disease: Economic impact of disease diagnosis and treatment

AIM: To model clinical and economic benefits of capsule endoscopy (CE) compared to ileo-colonoscopy and small bowel follow-through (SBFT) for evaluation of suspected Crohn's disease (CD).METHODS: Using decision analytic modeling, total and yearly costs of diagnostic work-up for suspected CD were calculated, including procedure-related adverse events,hospitalizations, office visits, and medications. The model compared CE to SBFT following ileo-colonoscopy and secondarily compared CE to SBFT for initial evaluation.RESULTS: Aggregate charges for newly diagnosed,medically managed patients are approximately $8295.Patients requiring aggressive medical management costs are $29 508; requiring hospitalization, $49 074.At sensitivity > 98.7% and specificity of > 86.4%, CE is less costly than SBFT.CONCLUSION: Costs of CE for diagnostic evaluation of suspected CD is comparable to SBFT and may be used immediately following ileo-colonoscopy.     

Palmitoylation in Crohn’s disease: Current status and future directions

S-palmitoylation is one of the most common post-translational modifications in nature; however, its importance has been overlooked for decades. Crohn’s disease (CD), a subtype of inflammatory bowel disease (IBD), is an autoimmune disease characterized by chronic inflammation involving the entire gastrointestinal tract. Bowel damage and subsequent disabilities caused by CD are a growing global health issue. Well-acknowledged risk factors for CD include genetic susceptibility, environmental factors, such as a westernized lifestyle, and altered gut microbiota. However, the pathophysiological mechanisms of this disorder are not yet comprehensively understood. With the rapidly increasing global prevalence of CD and the evident role of S-palmitoylation in CD, as recently reported, there is a need to investigate the relationship between CD and S-palmitoylation. In this review, we summarize the concept, detection, and function of S-palmitoylation as well as its potential effects on CD, and provide novel insights into the pathogenesis and treatment of CD.