Wireless capsule video endoscopy compared to barium follow-through and computerised tomography in patients with suspected Crohn's disease--final report

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.

Approach to the adult patient with chronic diarrhea: A literature review

Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.

Approach to the adult patient with chronic diarrhea: a literature review

Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.

The role of small bowel endoscopy for Crohn's disease

PURPOSE OF REVIEW

The review discusses the roles of small bowel capsule endoscopy and deep enteroscopy in patients with Crohn's disease. It highlights recent advances in the field and identifies areas where evidence is lacking.

RECENT FINDINGS

Small bowel capsule endoscopy has an important role in the follow-up of patients with Crohn's disease after escalation of therapy and in the postoperative assessment period following surgical resection. Device-assisted enteroscopy offers the therapeutic advantage of small bowel dilatation, which may result in a reduction in the number of surgical resections required, thus avoiding long-term complications, such as short bowel syndrome and malabsorption.

SUMMARY

Capsule endoscopy has an established role in the diagnosis and management of small bowel Crohn's disease. It is used in the setting of suspected Crohn's disease when ileocolonoscopy is negative and for the assessment of extent of small bowel disease in established Crohn's disease. It is relatively well tolerated because of the provision of patency capsule endoscopy to minimize the risk of inadvertent capsule retention. Device-assisted enteroscopy aids with the diagnosis of Crohn's disease as it enables histology to be taken from inflamed areas within the small bowel. Therapeutic procedures can be carried out during device-assisted enteroscopy including dilatation of Crohn's disease-related strictures and retrieval of retained capsules.

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.

Diagnostic Benefit of Simultaneous Capsule Endoscopy Using Two Different Systems

Background/Aims

Capsule endoscopy (CE) is a noninvasive test for diagnosing small bowel disorders. However, several studies reported that the CE-based visualization is suboptimal. This study, the first to use two CEs simultaneously, aimed at evaluating the diagnostic ability of dual CE.

Methods

Dual CE procedures were prospectively conducted. All patients completed bowel cleansing 2 hours before examination. Subsequently, they simultaneously swallowed two capsules: MiroCam (IntroMedic, Seoul, Korea) and PillCam SB3 (Medtronic, Minneapolis, USA). We assessed the completeness and feasibility of small bowel examination and the detection rate of duodenal papilla and diagnostic yield.

Results

Twenty consecutive patients who underwent complete small bowel examination with dual CE were enrolled in the study. The mean time of small bowel passage was 245 ± 99 min. Dual CE examination increased the duodenal papilla detection rate to up to 75% (versus PillCam SB3 alone (P = 0.031) and MiroCam alone (P = 0.063)) and overall diagnostic yield to up to 70% (P = 0.063) in comparison to single CE. Adverse events or electrical interference during data transmission between the two capsule endoscopes were not detected.

Conclusions

In this study, we found that dual CE enhances diagnostic accuracy and could increase the diagnostic power of existing CE systems using simply applicable methods. This trial is registered with KCT0002541.

Practice patterns and clinical significance of use of capsule endoscopy in suspected and established Crohn's disease

Background/Aims

Although the role of capsule endoscopy (CE) in Crohn's disease (CD) has expanded, CE is not used routinely for diagnosing and evaluating CD in Korea. We aimed to investigate current patterns of practice and evaluate the clinical significance of the use of CE in CD in Korean patients.

Methods

Among 651 CE procedures performed for various indications, we retrospectively analyzed the medical records of patients who underwent CE in 57 cases of suspected CD (sCD) and 14 cases of established CD (eCD).

Results

In the sCD group, CE was most commonly used for the initial diagnosis of CD (54.4%). Capsule retention was found in only 1 patient in the eCD group (1/71, 1.4%). In the sCD group, 28.1% of patients were diagnosed with CD on the basis of CE findings; other diseases diagnosed included tuberculous enteritis (7.0%), non-steroidal anti-inflammatory drug-induced enteropathy (5.3%), and other enteritis (17.5%). Only 11.5% of patients with eCD (14/122) underwent CE. The indication for CE in the 14 patients with eCD was to assess disease extent and activity. The overall diagnostic yield of CE was 59.7%. Therapeutic strategies were changed in 70.2% of patients in the sCD group and 50% of those in the eCD group based on CE findings.

Conclusions

In clinical practice, CE was most commonly indicated for the initial diagnosis of CD and was not generally performed in patients with eCD. CE appears to be an effective diagnostic modality for evaluating sCD and is useful for determining therapeutic strategies for patients with sCD and those with eCD.

Effectiveness of Capsule Endoscopy Compared with Other Diagnostic Modalities in Patients with Small Bowel Crohn's Disease: A Meta-Analysis

Background/Aims

As a result of the rapid development of medical diagnostic tools, physicians require concrete evidence to evaluate the effectiveness of the tools. We aimed to investigate the effectiveness and additional diagnostic benefits of capsule endoscopy (CE) in patients with small bowel Crohn’s disease (CD).

Methods

We performed a systematic search of databases, including MEDLINE, EMBASE, and the Cochrane Library, as well as eight domestic databases. Two reviewers independently screened all references. Diagnostic data from the studies were collected, and a meta-analysis was performed.

Results

Twenty-four studies were included. In cases of suspected CD, CE demonstrated a superior diagnostic yield compared with small bowel follow-through (SBFT) and enteroclysis (EC); however, there was no difference compared with computed tomography enterography or magnetic resonance enterography. In cases with established CD, CE demonstrated a higher diagnostic yield only compared with EC. In the detection of terminal ileum lesions, CE exhibited a significantly increased detection rate compared with ileoscopy.

Conclusions

The findings of our meta-analysis indicate that CE is superior to SBFT and EC in the evaluation of suspected CD cases. CE is also a more effective diagnostic modality in patients with established CD compared with EC.

Where do I see minimally invasive endoscopy in 2020: clock is ticking

Since it was introduced 17 years ago, capsule endoscopy has become an important diagnostic tool for the small bowel. Three generations of the original small bowel capsule have been developed since (PillCam SB3, Medtronic, USA), and four competitors were introduced for the small bowel. A non-video patency capsule (Agile patency capsule, Medtronic, USA) was also developed, in order to confirm patency and thus avoid retention in the GI tract. Moreover, capsules viewing other organs of the body (esophagus, colon) as well as three different magnetic guided capsules that visualize the stomach as good as optical endoscopy (OE) have been developed. Over 2,000 articles looking at the efficacy of the small bowel capsule in different clinical situations were published since then. Studies are comparing capsule endoscopy versus other modalities in various indications, looking at preparations aiming to improve the diagnostic yield and at technical aspects. The present paper, describes the available capsules in the market and my biased future expectations.

Capsule endoscopy for the diagnosis and follow up of Crohn's disease: a comprehensive review of current status

Capsule endoscopy (CE) has revolutionized the diagnosis and monitoring of small bowel Crohn’s disease (CD). The procedure is patient friendly and noninvasive, and compared to cross-sectional imaging, CE allows a direct and detailed evaluation of the entire small bowel mucosa with a high sensitivity for the earliest lesions of CD. Today, CE is the leading modality for visualizing the small bowel in suspected CD, and validated activity indices are available for the follow up of patients with established CD. CE of the entire gastrointestinal tract (panenteric CE) was recently introduced as a new diagnostic approach in patients examined for CD, and preliminary results are promising. There are important limitations, involving mainly capsule retention. Furthermore, a diagnostic criterion for CD has never been validated, and lesions detected by CE are not specific for CD. Hence, concern has been raised about a low specificity compared to other diagnostic modalities. Important questions about the optimal bowel preparation, selection of patients for CE and the optimal reading protocol remain to be clarified. The aim of this review is to evaluate the performance of CE for diagnosing CD and assess disease activity in known CD; to compare the diagnostic accuracy of CE to that of cross-sectional imaging; to discuss limitations; and to define the place of CE in the diagnostic algorithm in suspected or known CD.

The role of small bowel capsule endoscopy and ileocolonoscopy in patients with nonspecific but suggestive symptoms of Crohn's disease

OBJECTIVES

Ileocolonoscopy (IC) and small bowel capsule endoscopy (SBCE) are essential tools in the investigation of suspected small bowel Crohn's disease (CD). Overutilization of SBCE should be avoided as it leads to unwanted healthcare expenses; thus, it is recommended when IC is normal and CD is still highly suspected. Our aim was to compare the role of SBCE and IC in the investigation of suspected CD irrespective of its location and assess the additional diagnostic benefit of SBCE over IC.

METHODS

This was a retrospective study of 91 patients with chronic abdominal pain and/or diarrhea. All patients were evaluated with both colonoscopy (with terminal ileum intubation where possible) and SBCE. The severity of inflammation on SBCE was assessed using the Lewis Score. Endoscopic findings were analyzed toward CD diagnosis.

RESULTS

The sensitivity of IC and SBCE in the diagnosis of either small bowel or colonic CD was 81.82 and 63.64%, whereas the specificity was 77.50 and 92.50%, respectively. Positive and negative predictive value was 33.33 and 96.88% for IC, as well as 53.85 and 94.87% for SBCE. Area under receiver operating characteristic curve was 0.797 for IC and 0.781 for SBCE. IC was superior to SBCE in diagnosing small and large bowel CD. SBCE showed the true extent of CD in one patient missed by IC. It identified lesions suggestive of CD in three patients with normal IC, one of whom was finally diagnosed with CD.

CONCLUSION

IC should be the initial diagnostic test in patients with nonspecific, but suggestive symptoms of CD. SBCE offers additional information on small bowel mucosa and disease extent.

ACR Appropriateness Criteria Crohn Disease

Crohn disease is a chronic inflammatory disorder involving the gastrointestinal tract, characterized by episodic flares and times of remission. Underlying structural damage occurs progressively, with recurrent bouts of inflammation. The diagnosis and management of this disease process is dependent on several clinical, laboratory, imaging, endoscopic, and histologic factors. In recent years, with the maturation of CT enterography, and MR enterography, imaging has played an increasingly important role in relation to Crohn Disease. In addition to these specialized examination modalities, ultrasound and routine CT have potential uses. Fluoroscopy, radiography, and nuclear medicine may be less beneficial depending on the clinical scenario. The imaging modality best suited to evaluating this disease may change, depending on the target population, severity of presentation, and specific clinical situation. This document presents seven clinical scenarios (variants) in both the adult and pediatric populations and rates the appropriateness of the available imaging options. They are summarized in a consolidated table, and the underlying rationale and supporting literature are presented in the accompanying narrative. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Capsule Endoscopy for Crohn's Disease: Current Status of Diagnosis and Management

Crohn's disease (CD) is an idiopathic inflammatory bowel disease involving the small and/or large intestine. More than 50% of Western CD patients and up to 88% of Asian CD patients may have small intestinal involvement. Video capsule endoscopy (VCE) has a higher diagnostic yield than small bowel barium radiography and computed tomography enterography for the detection of small intestinal involvement of CD. VCE also provides diagnostic yields comparable to magnetic resonance- (MR-) based enterography or enteroclysis and may have several advantages over MR-based tests for the detection of early small intestinal lesions. Several studies have suggested the use of VCE-based disease activity scoring systems to evaluate small intestinal mucosal disease activity, although their clinical relevance needs to be further studied. A possible indication for VCE is recurrence monitoring after complete surgical excision of CD-involved segments but its usefulness and efficacy compared with conventional endoscopy should be evaluated. The capsule retention rate ranges from 0 to 5.4% in suspected CD patients and from 0 to 13.2% in established CD patients. If VCE is necessary, significant small bowel stricture should be ruled out before VCE by performing a patency capsule study and/or small bowel radiological study in suspected or established CD patients.

Diagnostic modalities for the evaluation of small bowel disorders

PURPOSE OF REVIEW

This review summarizes the recent developments in the evaluation of small bowel disorders using videocapsule endoscopy (VCE) and serological and breath-test biomarkers.

RECENT FINDINGS

The ability to visualize the small bowel was revolutionized with the introduction of VCE technology. VCE allows for accurate, noninvasive visualization of the small bowel mucosa. This device is invaluable in the investigation of obscure gastrointestinal bleeding (OGIB), occult bleeding with iron deficiency anaemia, small bowel Crohn's disease (CD), small bowel neoplasms and other mucosal disorders. Recent studies underscored the utility of VCE for documenting the extent and severity of small bowel CD as well as monitoring activity after therapy. The accuracy of the discrimination between small bowel tumours and benign bulges has been improved by a novel endoscopic algorithm. The accuracy of VCE was also evaluated as a potential noninvasive alternative to small bowel biopsies in suspected celiac disease. New findings have been made using breath tests and other biomarkers for the diagnosis of celiac disease, irritable bowel syndrome and bacterial overgrowth.

SUMMARY

VCE as well as breath-test biomarkers play a major and expanding role in the diagnosis and monitoring of various small bowel disorders.

Inflammatory bowel disease: clinical aspects and treatments

Inflammatory bowel disease (IBD) is defined as a chronic intestinal inflammation that results from host-microbial interactions in a genetically susceptible individual. IBDs are a group of autoimmune diseases that are characterized by inflammation of both the small and large intestine, in which elements of the digestive system are attacked by the body’s own immune system. This inflammatory condition encompasses two major forms, known as Crohn’s disease and ulcerative colitis. Patients affected by these diseases experience abdominal symptoms, including diarrhea, abdominal pain, bloody stools, and vomiting. Moreover, defects in intestinal epithelial barrier function have been observed in a number of patients affected by IBD. In this review, we first describe the types and symptoms of IBD and investigate the role that the epithelial barrier plays in the pathophysiology of IBD as well as the major cytokines involved. We then discuss steps used to diagnose this disease and the treatment options available, and finally provide an overview of the recent research that aims to develop new therapies for such chronic disorders.

Advanced endoscopic imaging techniques in Crohn's disease

BACKGROUND

Endoscopy is of pivotal importance in Crohn's disease (CD) patients for diagnosis, surveillance and assessment of disease activity and extent. Device-assisted enteroscopy (DAE) and small-bowel capsule endoscopy (SBCE) have recently changed our endoscopic approach to small-bowel imaging. Furthermore, new advanced endoscopic imaging techniques have been implemented into clinical practice to improve both characterization of mucosal inflammation and detection of dysplastic lesions.

AIM

To provide readers with a review about the concept of advanced endoscopic imaging for the diagnosis and characterization of CD.

METHODS

A literature search on the use of advanced endoscopy techniques in IBD patients was performed.

RESULTS

DAE and SBCE allow for deep enteroscopy with high diagnostic yields and low complication's rate but their collocation in the diagnostic algorithm is still not clearly defined. Dye-based chromoendoscopy (DBC) and magnification chromoendoscopy improved dysplasia's detection in long standing colitis and prediction of inflammatory activity and extent. Dye-less chromoendoscopy (DLC) might offer the potential to replace conventional DBC for surveillance. However, both narrow band imaging and i-scan have already shown to significantly improve activity and extent assessment in comparison to white-light endoscopy. Confocal laser endomicroscopy (CLE) can detect more dysplastic lesions in surveillance colonoscopy and predict neoplastic and inflammatory changes with high accuracy compared to histology. Moreover, CLE-based molecular imaging may anticipate the therapeutic responses to biological therapy. Endocytoscopy can identify in vivo inflammatory mucosal cells harboring a new method to assess the mucosal activity.

CONCLUSIONS

Recent progresses in small-bowel enteroscopy offer several potential benefits to improve both diagnosis and characterization of CD. New advanced endoscopic imaging techniques can improve detection of dysplasia and refine mucosal healing assessment, even looking beyond the morphological parameters revealed by conventional endoscopic imaging.

Capsule endoscopy in the small bowel Crohn's disease

CD is a chronic inflammatory disorder associated to mucosal and transmural inflammation of the bowel wall. It is well known that CD can affect the entire gastrointestinal. Therefore, ileocolonoscopy and biopsies of the terminal ileum as well as of each colonic segment to look for microscopic evidence of CD are the first-line procedures to establish the diagnosis. However, it has been observed that up to 30% of the patients have only small bowel involvement. Evaluation of the small bowel has been made with radiological procedures, barium radiography, and abdominal computed tomography or by ileocolonoscopy or enteroscopy, but they have many recognized limitations. CE is undoubtedly a very useful diagnostic tool proposed to observe small-bowel lesions undetectable by conventional endoscopy or radiologic studies. We review different studies that have been published reporting the use of CE in suspected and evaluation of the extension or the recurrence in CD and also its use in pediatric population and its complications.

Double-balloon enteroscopy in the diagnosis of suspected isolated Crohn's disease of the small bowel

BACKGROUND AND AIM

Diagnosis of Crohn's disease (CD) with isolated involvement of the small bowel remains a major challenge. Diagnostic procedures allowing direct insight into the midgut have become available with the introduction of double-balloon enteroscopy (DBE) and video-capsule endoscopy (VCE). The aim of the present study was to evaluate the role of DBE in the diagnosis of isolated CD of the small bowel.

METHODS

Sixteen patients (seven males) with suspected CD of the small bowel after exclusion of abnormal changes in the upper gastrointestinal tract and colon by esophagogastroduodenoscopy and colonoscopy including histology underwent DBE and high-resolution transabdominal ultrasound.

RESULTS

In seven of 16 (44%) patients, abnormal macroscopic findings were detected by DBE (e.g. ileitis terminalis, inflammatory stenosis, aphthous lesions or jejunal ulcers). In one of thecases, histology confirmed pathognomonic findings consistent with CD. However, the diagnosis of CD was confirmed in 11/16 (69%) patients taking into account the clinical presentation and course of the disease as well as the endoscopic and imaging results.

CONCLUSIONS

In cases of CD with clinical expression limited to the small bowel, DBE is a helpful tool. Nevertheless, in these patients, the combination of clinical findings and additional imaging modalities is required for confirmation of the diagnosis. A suggestive medical history, high-resolution ultrasound, EGD and colonoscopy lead the algorithm before the assessment with DBE.

Role of capsule endoscopy in inflammatory bowel disease

Videocapsule endoscopy (VCE) has revolutionized our ability to visualize the small bowel mucosa. This modality is a valuable tool for the diagnosis of obscure small bowel Crohn’s disease (CD), and can also be used for monitoring of disease activity in patients with established small-bowel CD, detection of complications such as obscure bleeding and neoplasms, evaluation of response to anti-inflammatory treatment and postoperative recurrence following small bowel resection. VCE could also be an important tool in the management of patients with unclassified inflammatory bowel disease, potentially resulting in reclassification of these patients as having CD. Reports on postoperative monitoring and evaluation of patients with ileal pouch-anal anastomosis who have developed pouchitis have recenty been published. Monitoring of colonic inflammatory activity in patients with ulcerative colitis using the recently developed colonic capsule has also been reported. Capsule endoscopy is associated with an excellent safety profile. Although retention risk is increased in patients with small bowel CD, this risk can be significanty decreased by a routine utilization of a dissolvable patency capsule preceding the ingestion of the diagnostic capsule. This paper contains an overview of the current and future clinical applications of capsule endoscopy in inflammatory bowel disease.

Wireless capsule endoscopy

Over the last decade, WCE has established itself as a valuable test for imaging the small intestine. It is a safe and relatively easy procedure to perform that can provide valuable information in the diagnosis of small-bowel conditions. Its applications still remain limited within the esophagus and colon. Future developments may include improving visualization within the esophagus and developing technologies that may allow manipulation of the capsule within the GI tract and biopsy capabilities.

Comparison of MR enteroclysis with video capsule endoscopy in the investigation of small-intestinal disease

Purpose

To evaluate the diagnostic accuracy of MR enteroclysis and to compare it to video capsule endoscopy (VCE) in the analysis of suspected small-bowel disease.

Methods

We performed a retrospective analysis of 77 patients who underwent both MR enteroclysis and VCE and compared the findings of these studies with the findings of enteroscopy, surgery, or with the results of clinical follow-up lasting ≥2 years.

Results

Findings included malignant neoplasms (n = 13), benign neoplasms (n = 10), refractory celiac disease (n = 4), Crohn’s disease (n = 2) and miscellaneous conditions (n = 10). Specificity of MR enteroclysis was higher than that of VCE (0.97 vs. 0.84, P = 0.047), whereas sensitivity was similar (0.79 vs. 0.74, P = 0.591). In 2/32 (6.3%) patients with both negative VCE and negative MR enteroclysis a positive diagnosis was established, compared to 5/11 (45.5%) patients in whom VCE was positive and MR enteroclysis was negative (likelihood ratio 8.1; P = 0.004), 9/11 (81.8%) patients in whom MR enteroclysis was positive and VCE was negative (likelihood ratio 23.5; P < 0.0001), and all 23 patients in whom both VCE and MR enteroclysis showed abnormalities (likelihood ratio 60.8; P < 0.0001).

Conclusions

VCE and MR enteroclysis are complementary modalities. In our study-population, MR enteroclysis was more specific than VCE, while both produced the same sensitivity.

Clinical applications of small bowel capsule endoscopy

Video capsule endoscopy has revolutionized our ability to visualize the entire small bowel mucosa. This modality is established as a valuable tool for the diagnosis of obscure gastrointestinal bleeding, Crohn's disease, small bowel tumors, and other conditions involving the small bowel mucosa. This review includes an overview of the current and potential future clinical applications of small bowel video endoscopy.

Clinical applications of small bowel capsule endoscopy

Video capsule endoscopy has revolutionized our ability to visualize the entire small bowel mucosa. This modality is established as a valuable tool for the diagnosis of obscure gastrointestinal bleeding, Crohn’s disease, small bowel tumors, and other conditions involving the small bowel mucosa. This review includes an overview of the current and potential future clinical applications of small bowel video endoscopy.

Novel imaging enhancements in capsule endoscopy

Video capsule endoscopy that was launched 10 years ago has become a first-line procedure for examining the small bowel. The most common indications for capsule endoscopy are obscure gastrointestinal bleeding, Crohn's disease, polyposis syndromes, and evaluation of patients with complicated celiac disease. The ideal capsule should improve the quality of the image and have a faster frame rate than the currently available one. There should be a therapeutic capsule capable of performing a biopsy, aspirating fluid, delivering drugs, and measuring the motility of the small bowel wall. Another major leap forward would be the capability of remote control of capsule's movement in order to navigate it to reach designated anatomical areas for carrying out a variety of therapeutic options. Technology for improving the capability of the future generation capsules almost within grasp and it would not be surprising to witness the realization of these giant steps within the coming decade. In this review we will focus on the current clinical applications of capsule endoscopy for imaging of the small bowel and colon and will additionally give an outlook on future concepts and developments of capsule endoscopy.

When Crohn's disease is in remission, more patients complete capsule endoscopy study but less lesions are identified

BACKGROUND AND AIMS

Wireless capsule endoscopy (WCE) is used in Crohn's disease (CD) to define disease extent. We aimed to define WCE detection rate of small bowel ulcerative lesions and completion rate in CD patients.

PATIENTS AND METHODS

A total of 102 consecutive CD patients, who successfully passed patency capsule, were matched to 102 controls. WCE was performed in both patients (in acute phase and CD clinical remission) and controls.

RESULTS

Eighty-six (84%) controls versus 62 (61%) patients in the acute phase ( P = 0.003) and 96 (94%) in remission ( P = 0.02) completed WCE study. Gastric passing time was 48 ± 66 min in controls, 66 ± 82 min in CD acute phase ( P = 0.03) and 30 ± 21 min in remission ( P = 0.07). Small bowel passing time was 276 ± 78 min in controls, 299 ± 78 min in the acute phase of CD ( P = 0.04) and 248 ± 89 min in remission ( P = 0.01). Mean capsule endoscopy Crohn's disease activity index (CECDAI) score was 14 ± 6 in acute small bowel CD, 12 ± 7 in acute small-large bowel CD ( P = 0.08) and 2 ± 2 in both CD types while in remission ( P = 1.00). Small bowel ulcerative lesions in the acute phase were more frequently in distal small bowel. Aphthous ulcers were frequent a month after entering clinical remission and tend to disappear gradually later on. No ulcerative lesions were present in deep remission. Patency capsule is rather safe to exclude small bowel obstruction.

CONCLUSIONS

(1) A high percentage of patients with active CD do not complete small bowel study with WCE. (2) Small bowel ulcerative lesions in clinical remission were less severe, although at least 6 months are needed in order for them to disappear.

Inpatient capsule endoscopy leads to frequent incomplete small bowel examinations

AIM: To examine the predictive factors of capsule endoscopy (CE) completion rate (CECR) including the effect of inpatient and outpatient status.

METHODS: We identified 355 consecutive patients who completed CE at Rush University Medical Center between March 2003 and October 2005. Subjects for CE had either nothing by mouth or clear liquids for the afternoon and evening of the day before the procedure. CE exams were reviewed by two physicians who were unaware of the study hypotheses. After retrospective analysis, 21 cases were excluded due to capsule malfunction, prior gastric surgery, endoscopic capsule placement or insufficient data. Of the remaining 334 exams [264 out-patient (OP), 70 in-patient (IP)], CE indications, findings, location of the patients [IP vs OP and intensive care unit (ICU) vs general medical floor (GMF)] and gastrointestinal transit times were analyzed. Statistical analysis was completed using SPSS version 17 (Chicago, IL). Chi-square, t test or fisher exact-tests were used as appropriate. Multivariate logistic regression analysis was used to identify variables associated with incomplete CE exams.

RESULTS: The mean age for the entire study population was 54.7 years. Sixty-one percent of the study population was female, and gender was not different between IPs vs OPs (P = 0.07). The overall incomplete CECR was 14% in our study. Overt obscure gastrointestinal bleeding (OGB) was a significantly more common indication for the IP CE (P = 0.0001), while abdominal pain and assessment of IBD were more frequent indications for the OP CE exams (P = 0.002 and P = 0.01, respectively). Occult OGB was the most common indication and arteriovenous malformations were the most common finding both in the IPs and OPs. The capsule did not enter the small bowel (SB) in 6/70 IPs and 8/264 OPs (P = 0.04). The capsule never reached the cecum in 31.4% (22/70) of IP vs 9.5% (25/ 264) of OP examinations (P < 0.001). The mean gastric transit time (GTT) was delayed in IPs compared to OPs, 98.5 ± 139.5 min vs 60.4 ± 92.6 min (P = 0.008). Minimal SB transit time was significantly prolonged in the IP compared to the OP setting [IP = 275.1 ± 111.6 min vs OP = 244.0 ± 104.3 min (P = 0.037)]. CECR was also significantly higher in the subgroup of patients with OGB who had OP vs IP exams (95% vs 80% respectively, P = 0.001). The proportion of patients with incomplete exams was higher in the ICU (n = 7/13, 54%) as compared to the GMF (n = 15/57, 26%) (P = 0.05). There was only a single permanent SB retention case which was secondary to a previously unknown SB stricture, and the remaining incomplete SB exams were due to slow transit. Medications which affect gastrointestinal system motility were tested both individually and also in aggregate in univariate analysis in hospitalized patients (ICU and GMF) and were not predictive of incomplete capsule passage (P > 0.05). Patient location (IP vs OP) and GTT were independent predictors of incomplete CE exams (P < 0.001 and P = 0.008, respectively).

CONCLUSION: Incomplete CE is a multifactorial problem. Patient location and related factors such as severity of illness and sedentary status may contribute to incomplete exams.

The role of capsule endoscopy in evaluating inflammatory bowel disease

Capsule endoscopy is a relatively new technology available in the investigation of IBD. Its place in the algorithm of evaluating IBD is being refined. Capsule endoscopy has the ability to visualize the entire SB with very few complications. It is a sensitive test for the diagnosis of mucosal changes, but should be viewed as complementary to other radiologic evaluations, such as CTE and MRE. Capsule endoscopy is nonspecific and its findings have to be interpreted with caution and in the right clinical setting, because up to one fifth of normal individuals may have subtle changes in the small intestine. Care should also be taken to exclude NSAID use because it mimics findings seen in CD. Capsule endoscopy is an exciting technology that opened the possibility of the evaluation of the SB in the era of “deep remission.” It is best applied in patients with a high clinical suspicion for IBD after unremarkable colonoscopy with terminal ileal intubation and radiologic investigation.

Small bowel endoscopy in inflammatory bowel disease

The last decade has witnessed a revolution in small bowel (SB) endoscopy technologies. Endoscopists are no longer confined to the use of push enteroscopy or the significantly more invasive intra-operative enteroscopy: SB capsule endoscopy (SBCE) and device assisted enteroscopy (DAE) have rapidly enabled endoscopic visualisation of the entire SB without the need for surgery. DAE goes a step further by allowing tissue sampling and the application of endotherapy. These developments have also been parallelled by rapid advances in dedicated radiological SB imaging technologies. Although it is clear that SBCE and DAE may have a significant role in the diagnosis and management of IBD patients, their respective place in relation to other technologies within the clinical paradigm of IBD is as yet unclear. This review outlines the current evidence base relating to these endoscopic technologies and their impact in the diagnosis and management of IBD and highlights current international recommendations.

Does capsule endoscopy have an added value in patients with perianal disease and a negative work up for Crohn's disease?

AIM: To investigate the role of capsule endoscopy in patients with persistent perianal disease and negative conventional work up for Crohn’s disease (CD).

METHODS: Patients with perianal disease (abscesses, fistulas, recurrent fissures) were evaluated for underlying CD. Patients who had a negative work up, defined as a negative colonoscopy with a normal ileoscopy or a normal small bowel series or a normal CT/MR enterography, underwent a Pillcam study of the small bowel after signing informed consent. Patients using nonsteroidal anti-inflammatory drugs or who had a history of inflammatory bowel disease or rheumatic disease were excluded.

RESULTS: We recruited 26 patients aged 21-61 years (average 35.6 years), 17 males and 9 females. One case could not be evaluated since the capsule did not leave the stomach. In 6 of 25 (24%) patients with a negative standard work up for Crohn's disease, capsule endoscopy (CE) findings were consistent with Crohn's disease of the small bowel. Family history of CD, white blood cell, hemoglobin, erythrocyte sedimentation rate or C-reactive protein did not predict a diagnosis of CD. Capsule endoscopy findings led to a change in treatment.

CONCLUSION: In patients with perianal disease and a negative conventional work up to exclude CD, CE leads to incremental diagnostic yield of 24%.

Small bowel imaging in managing Crohn's disease patients

The small bowel is essential to sustain alimentation and small bowel Crohn's disease (CD) may severely limit its function. Small bowel imaging is a crucial element in diagnosing small bowel CD, and treatment control with imaging is increasingly used to optimize the patients outcome. Thereby, capsule endoscopy, Balloon-assisted enteroscopy, and Magnetic resonance imaging have become key players to manage CD patients. In this review, role of small bowel imaging is detailed discussed for use in diagnosing and managing Crohn's disease patients.

Swallowable wireless capsule endoscopy: progress and technical challenges

Wireless capsule endoscopy (WCE) offers a feasible noninvasive way to detect the whole gastrointestinal (GI) tract and revolutionizes the diagnosis technology. However, compared with wired endoscopies, the limited working time, the low frame rate, and the low image resolution limit the wider application. The progress of this new technology is reviewed in this paper, and the evolution tendencies are analyzed to be high image resolution, high frame rate, and long working time. Unfortunately, the power supply of capsule endoscope (CE) is the bottleneck. Wireless power transmission (WPT) is the promising solution to this problem, but is also the technical challenge. Active CE is another tendency and will be the next geneion of the WCE. Nevertheless, it will not come true shortly, unless the practical locomotion mechanism of the active CE in GI tract is achieved. The locomotion mechanism is the other technical challenge, besides the challenge of WPT. The progress about the WPT and the active capsule technology is reviewed.

Advanced endoscopic imaging for diagnosis of Crohn's disease

Endoscopy in IBD has tremendous importance to diagnose inflammatory activity, to evaluate therapeutic success and for the surveillance of colitis associated cancer. Thus it becomes obvious that there is a need for new and more advanced endoscopic imaging techniques for better characterization of mucosal inflammation and early neoplasia detection in IBD. This paper describes the concept of advanced endoscopic imaging for the diagnosis and characterization of Crohn's disease, including magnification endoscopy, chromoendoscopy, balloon-assisted enteroscopy, capsule endoscopy, confocal laser endomicroscopy, and endocytoscopy.

Improved diagnostic yield with severity of bleeding

OBJECTIVE

Video capsule endoscopy (VCE) is an important tool for non-invasive imaging of the small bowel. Whether there is a dose-related effect of anemia severity on the diagnostic yield of VCE is unknown. The aim of this study was to determine the influence of anemia severity on VCE outcome measures.

METHODS

VCE studies from the Sacramento Veterans Affairs Medical Center for 300 consecutive patients were retrospectively screened. Those with anemia were selected. Patients were grouped as mildly, moderately or severely bleeding. Outcomes data including completion of study, diagnostic yield and further intervention were compared.

RESULTS

Of the 300 patients, 210 (70%) were found to have anemia. Overall 32 (15.24%) patients were mildly, 145 (69.05%) were moderately and 33 (15.71%) were severely bleeding. The diagnostic yield was significantly higher in severe (72.73%) relative to moderate (32.41%) and mild bleeding (12.50%); P = 0.0001. Significantly more angioectasias were detected in severely bleeding patients (42.42%) than in those bleeding moderately (14.48%) and mildly (0.00%), P = 0.0001. The ability of VCE to guide further intervention was significantly higher in patients bleeding severely (69.70%, P = 0.006).

CONCLUSIONS

Our data showed a significant increase in diagnostic yield with the increasing degree of anemia. Relative difference in hemoglobin rather than absolute values may be a better predictor. The ability of VCE to guide further intervention reached significance in severely bleeding patients. The hypothesis that use of VCE prior to esophagogastroduodenoscopy or colonoscopy in the severely bleeding group deserves to be evaluated.

New concepts in intestinal imaging for inflammatory bowel diseases

In the last decade, multiple imaging technologies have been developed that improve visualization of the mucosal, mural, and perienteric inflammation associated with inflammatory bowel diseases. Whereas these technologies have traditionally been used to detect and stage suspected enteric inflammation, we review new, emerging roles in detecting clinically occult inflammation (in asymptomatic patients) and inflammatory complications, predicting response prior to therapy, assessing response after therapy, and enteric healing. We compare the relative performance of these technologies in detecting inflammation, focusing on their advantages and disadvantages and how they might complement each other. We also discuss their potential benefits for patients and clinical trials, reviewing technologic developments and areas of research that could provide important insights into the pathophysiology of inflammatory bowel diseases-related enteric inflammation.

Small bowel capsule endoscopy vs conventional techniques in patients with symptoms highly compatible with Crohn's disease

BACKGROUND & AIMS

The diagnostic role of Small Bowel Capsule Endoscopy (SBCE) in Crohn's Disease (CD) is under investigation. In a prospective study we investigated the diagnostic role of SBCE in patients with symptoms highly compatible with CD and undefined diagnosis after conventional techniques.

METHODS

From September 2005 to May 2009, all patients with clinically suspected CD and not conclusive diagnosis after Ileocolonoscopy (IC), Small Bowel Follow Through (SBFT) and Small Intestine Contrast Ultrasonography (SICUS) were enrolled. Findings compatible with CD included: bowel wall thickness (BWT) >3mm (for SICUS), ulcers, stenosis/strictures, fistulae (for SICUS, SBFT); >5 aphtoid ulcers, deep ulcers and/or strictures (for SBCE).

RESULTS

Conventional techniques did not lead to a conclusive diagnosis in 30 patients (19 F, median age 31 years, range 8-57), showing chronic diarrhoea (n=27), abdominal pain (n=23), weight loss (n=5), fever (n=5), Iron Deficiency Anaemia (IDA)(n=5) and/or perianal disease (n=4). Findings compatible but not diagnostic for small bowel CD were detected in 19 (63%) by IC in 12 (40%) by SICUS and in 15 (50%) by SBFT. SBCE showed ileal lesions in 15 (50%) patients, including findings compatible with CD in 12 (40%). SBCE retention requiring surgery was observed in 1 patient. A significant concordance was observed between SBCE and IC k=0.33 C(k)=[0.25;0.42], but not between SBCE and SICUS k=0.13 IC(k)=[0.045;0.22] and between SBCE and SBFT k=0 IC(k)=[-0.089;0.089].

CONCLUSIONS

SBCE may detect lesions compatible with small bowel CD in almost one third of patients with symptoms highly compatible with CD and not conclusive diagnosis by using conventional techniques.

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 results 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 diagnosis of CD and unexplained symptoms. Finally, as no threshold for CD diagnosis has been agreed upon, a severity scale of mucosal disease activity has not been 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.

Double balloon enteroscopy in Crohn's disease: where are we now and where should we go?

Visualization of the entire small-bowel mucosa had not been possible until the development of the capsule endoscope (Pillcam, Given Imaging, Yoqneam, Israel). However, this device did not allow any endoscopic intervention. More recently, a double balloon endoscope has been developed that allows intubation of the entire small bowel. This endoscope contains a working channel that allows for all the interventions possible with standard colonoscopes. In this review we describe the instrument, techniques for its use, and its practical applications and capabilities. We review the experience to date for its use in various clinical indications for small-bowel inflammatory disease, its diagnostic and therapeutic yield and risks, and its role and potential in the diagnosis and treatment of inflammatory bowel disease.

Role of small bowel follow-through in diagnosing inflammation of the terminal ileum in pediatric patients

BACKGROUND

The small bowel follow-through (SBFT) is a noninvasive imaging modality for evaluating terminal ileum (TI) inflammation. The accuracy of this modality in pediatric patients is not well established.

PATIENTS AND METHODS

We retrospectively determined the sensitivity and specificity of SBFT for detecting TI inflammation diagnosed on histology in 93 pediatric patients studied in a single institution.

RESULTS

The mean age at the first study was 12.9 years (range 1.1-20.9 years). Forty-five percent were girls. Twenty-five patients (27%) had abnormal TIs on SBFT. Seventeen patients (18%) had TI inflammation diagnosed by biopsy. The sensitivity of SBFT was 59% and the specificity was 80% for detecting TI inflammation diagnosed on histology. Sensitivity and specificity did not change by demographic factors, final diagnoses, presenting symptoms, or laboratory parameters, reflecting the presence of intestinal inflammation.

CONCLUSIONS

The sensitivity and specificity of SBFT in pediatric patients were poor and did not vary with demographic factors, final diagnoses, presenting symptoms, or laboratory parameters. Prospective longitudinal studies comparing various imaging modalities (SBFT, magnetic resonance enterography, and capsule endoscopy) are required to determine which is the most effective tool for evaluating pediatric patients for TI inflammation.

Role of small bowel follow-through in diagnosing inflammation of the terminal ileum in pediatric patients

BACKGROUND

The small bowel follow-through (SBFT) is a noninvasive imaging modality for evaluating terminal ileum (TI) inflammation. The accuracy of this modality in pediatric patients is not well established.

PATIENTS AND METHODS

We retrospectively determined the sensitivity and specificity of SBFT for detecting TI inflammation diagnosed on histology in 93 pediatric patients studied in a single institution.

RESULTS

The mean age at the first study was 12.9 years (range 1.1-20.9 years). Forty-five percent were girls. Twenty-five patients (27%) had abnormal TIs on SBFT. Seventeen patients (18%) had TI inflammation diagnosed by biopsy. The sensitivity of SBFT was 59% and the specificity was 80% for detecting TI inflammation diagnosed on histology. Sensitivity and specificity did not change by demographic factors, final diagnoses, presenting symptoms, or laboratory parameters, reflecting the presence of intestinal inflammation.

CONCLUSIONS

The sensitivity and specificity of SBFT in pediatric patients were poor and did not vary with demographic factors, final diagnoses, presenting symptoms, or laboratory parameters. Prospective longitudinal studies comparing various imaging modalities (SBFT, magnetic resonance enterography, and capsule endoscopy) are required to determine which is the most effective tool for evaluating pediatric patients for TI inflammation.

Serologic markers: impact on early diagnosis and disease stratification in inflammatory bowel disease

Inflammatory bowel disease (IBD) is difficult to diagnose, and differentiating between ulcerative colitis (UC) and Crohn's disease (CD) can be challenging. Overlapping symptoms of UC and CD often delay diagnosis, despite availability of endoscopic, radiologic, and histologic tools. This delay in diagnosis is quite common in clinical practice, which may also delay initiation of appropriate treatment. Abnormal immune responses found in IBD have led to the use of serum biomarkers (eg, anti-Saccharomyces cerevisiae antibody [ASCA], perinuclear antineutrophil cytoplasmic antibody [pANCA], antibodies to flagellin [anti-CBir1]) to improve diagnostic confidence in IBD. These biomarkers are beginning to be used to stratify patients with UC and CD according to disease phenotype and risk of complications. Associations between quantity and quality of immune reactivity and severe disease phenotypes are increasingly evident. This suggests that serologic panels of multiple IBD biomarkers can be used to identify the relative risk of progression to complicated disease behaviors, and that this information may ultimately impact therapeutic decisions. This review discusses the diagnostic process and challenges in IBD, with emphasis on the role that serologic markers may play in addressing these challenges.

BP neural network classification for bleeding detection in wireless capsule endoscopy

Bleeding in the digestive tract is one of the most common gastrointestinal tract (GI) diseases, as well as the complication of some fatal diseases. Wireless capsule endoscopy (WCE) allows physicians to noninvasively examine the entire GI tract. However it is very laborious and time-consuming to inspect large numbers of WCE images, which limits the wider application of WCE. It is therefore important to develop an automatic and intelligent computer-aided bleeding detection technique. In this paper, a new method aimed at bleeding detection in WCE images is proposed. Colour texture features distinguishing the bleeding regions from non-bleeding regions are extracted in RGB and HSI colour spaces; then a neural network using the colour texture features as the feature vector inputs is designed to recognize the bleeding regions. The experiments demonstrate that the bleeding regions can be correctly recognized and clearly marked out. The sensitivity of the algorithm is 93% and the specificity is 96%.

Inter-observer agreement for detection of small bowel Crohn's disease with capsule endoscopy

OBJECTIVE

Compared to other modalities, capsule endoscopy (CE) has a high diagnostic yield for diagnosing small bowel Crohn's disease (CD). The aim of this study was to determine the inter-observer agreement for detection of small bowel CD with predefined diagnostic criteria.

MATERIAL AND METHODS

Thirty patients with suspected or known CD were included in the study. Observers were blind to patient histories, the results of ileo-colonoscopies, and small bowel examinations. More than three ulcerations (aphthous lesions or ulcers) or the presence of stenosis caused by inflammation or fibrosis was diagnostic of small bowel CD. Three observers with experience in gastrointestinal endoscopy and CE participated in the study.

RESULTS

The presence or absence of small bowel CD was determined with complete agreement in 23 patients, nine patients with and 14 without small bowel CD. The inter-observer agreement was substantial for the diagnosis (kappa = 0.68) and moderate for the localization of CD (kappa = 0.44). Aphthous lesions were detected with only fair agreement (kappa = 0.38). The time intervals to passage of the pylorus and ileo-caecal valve were detected with excellent intra-class correlation.

CONCLUSIONS

CE is performed with substantial inter-observer agreement for detection of small bowel CD. In the majority of patients, the presence or absence of small bowel CD is unequivocal. However, in patients with few or minor lesions, the diagnosis is observer dependent.

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.

Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohn's disease: a meta-analysis

OBJECTIVES

Capsule endoscopy (CE) has demonstrated superior performance compared with other modalities in its ability to detect early small-bowel (SB) Crohn's disease (CD), especially when ileoscopy is negative or unsuccessful. The aim of this study was to evaluate the diagnostic yield of CE compared with other modalities in patients with suspected and established CD using a meta-analysis.

METHODS

A thorough literature search for prospective studies comparing the diagnostic yield of CE with other modalities in patients with CD was undertaken. Other modalities included push enteroscopy (PE), colonoscopy with ileoscopy (C+IL), SB radiography (SBR), computed tomography enterography (CTE), and magnetic resonance enterography (MRE). Data on diagnostic yield among various modalities were extracted, pooled, and analyzed. Data on patients with suspected and established CD were analyzed separately. Weighted incremental yield (IYW) (diagnostic yield of CE-diagnostic yield of comparative modality) and 95% confidence intervals (CIs) of CE over comparative modalities were calculated.

RESULTS

A total of 12 trials (n=428) compared the yield of CE with SBR in patients with CD. Eight trials (n=236) compared CE with C+IL, four trials (n=119) compared CE with CTE, two trials (n=102) compared CE with PE, and four trials (n=123) compared CE with MRE. For the suspected CD subgroup, several comparisons met statistical significance. Yields in this subgroup were CE vs. SBR: 52 vs. 16% (IYw=32%, P<0.0001, 95% CI=16-48%), CE vs. CTE: 68 vs. 21% (IYw=47%, P<0.00001, 95% CI=31-63%), and CE vs. C+IL: 47 vs. 25% (IYw=22%, P=0.009, 95% CI=5-39%). Statistically significant yields for CE vs. an alternate diagnostic modality in established CD patients were seen in CE vs. PE: 66 vs. 9% (IYw=57%, P<0.00001, 95% CI=43-71%), CE vs. SBR: 71 vs. 36% (IYw=38%, P<0.00001, 95% CI=22-54%), and in CE vs. CTE: 71 vs. 39% (IYw=32%, P=or<0.0001, 95% CI=16-47%).

CONCLUSIONS

Our meta-analysis demonstrates that CE is superior to SBR, CTE, and C+IL in the evaluation of suspected CD patients. CE is also a more effective diagnostic tool in established CD patients compared with SBR, CTE, and PE.

Capsule endoscopy in small bowel tumors: a multicenter Korean study

BACKGROUND AND AIM

Capsule endoscopy (CE) has proven to be highly effective at detecting small bowel lesions in a variety of clinical conditions, but studies concerning the practical impact of CE on small bowel tumors are still scarce, especially in the Asian population. The aim of this study was to evaluate the diagnostic and therapeutic impact of CE in the field of small bowel tumors.

METHODS

CE records consecutively pooled from the beginning of use of CE in Korea, October 2001 until April 2008, in 14 centers throughout Korea were reviewed. Clinical information and CE video images of small bowel tumors were analyzed.

RESULTS

A total of 1332 cases undergoing CE were reviewed with all clinical indications. Small bowel tumors were diagnosed with CE in 57 (4.3%) of 1332 patients. The tumors were malignant in 33 cases, and included three adenocarcinomas, eight lymphomas, 20 gastrointestinal stromal tumors, and two metastatic cancers. The most frequent indications for CE in malignant tumors were obscure gastrointestinal bleeding, followed by abdominal pain and weight loss. Thirty of 57 tumors were identified exclusively by CE (diagnostic impact = 30/57), and they were smaller in size (mean, range: 14.3 mm, 2-35 mm) compared to the other tumors detected in radiological studies (48.7 mm, 10-110 mm). Seven patients underwent surgical resection (therapeutic impact = 7/57).

CONCLUSION

CE effectively identifies small bowel tumors that are undetectable by conventional radiological studies (diagnostic impact = 52.6%) and can critically change the therapeutic course (therapeutic impact = 12.3%).

ACR Appropriateness Criteria on Crohn's disease

In the past decade, new therapeutic agents have been developed that permit gastroenterologists to treat virtually all forms of Crohn's disease. The success of these treatments depends on an accurate diagnosis of the nature and extent of disease. Fortunately, radiologists now possess a powerful arsenal of imaging techniques to guide the choice of therapy. This article discusses the usefulness of both traditional and newer imaging techniques in the management of Crohn's disease and its various clinical presentations.