Jejunoileal Crohn's disease: a case-control study

Elevated fecal calprotectin: Does capsule endoscopy have a role in the diagnostic algorithm?

INTRODUCTION

The purpose of this study was to examine the utility of small bowel capsule endoscopy (SBCE) in the diagnostic pathway of patients that had elevated fecal calprotectin (FC) and normal colonoscopy.

METHODS

Patients with elevated FC and normal colonoscopy that underwent SBCE in the last 4 years were included. Patients were divided into 3 groups: group 1: patients with isolated small bowel Crohn's disease (SBCD) on SBCE; group 2: patients with elevated FC but normal SBCE; and group 3: patients with isolated terminal ileitis.

RESULTS

The study included 320 patients (group 1: 254 patients, group 2: 50 patients, and group 3: 16 patients). The median age was 42.5 years (IQR 26) across the three groups and 52.4% of the patients had a new diagnosis of SBCD. In group 1, active disease was identified distally in 247 patients (77.2%), proximal involvement in 90 patients (28.1%), and extensive SBCD in 68 patients (21.3%). Magnetic resonance enterography (MRE) was carried out in 229 (90.1%) patients in group 1 and was negative in 42 patients with SBCD. The diagnostic yield of SBCE was higher than that of MRE (p < 0.0001). In group 2, the final diagnoses included Helicobacter pylori infection (n = 2), NSAID use (n = 3), celiac disease (n = 2), and microscopic colitis (n = 1). The final diagnoses in group 3 were idiopathic terminal ileitis (n = 11), inflammatory bowel disease (n = 3), and infective terminal ileitis (n = 2).

CONCLUSION

SBCE influences the patient pathway even when negative/normal. It is better at identifying early SBCD, when compared with MRE.

The utility of capsule endoscopy in the phenotype of Crohn's disease. Data from England 2016-2021

BACKGROUND AND STUDY AIMS

Isolated small bowel Crohn's disease (SBCD) is reported to have a worse prognosis compared to other CD phenotypes. The aim of this study was to understand the correlation between Isolated SBCD and ileocolonic disease with blood and faecal biomarkers and also to identify differences in outcome and management between the two phenotypes.

PATIENTS AND METHODS

Patients with ileocolonic or isolated small bowel Crohn's Disease (SBCD) were identified from an existing capsule endoscopy (CE) database. Harvey Bradshaw Index (HBI), biomarkers: c-reactive protein (CRP) and faecal calprotectin (FC), Lewis score and findings on CE and subsequent follow up data were collected. SPSS was used to analyse the data.

RESULTS

In total 248 patients were included in the study. Patients were split into two groups- Isolated SBCD with 178 patient (median age 44 years (IQR 31-56); 41.5 % male) and Ileocolonic Crohn's with 70 patients (median age 31 years (IQR 22.7-49); 31.5 % male). A new diagnosis of SBCD was made in 38.7 % (n = 96), whilst 60.0 % (n = 144) had established CD. Patients with ileocolonic disease had a higher HBI in comparison to isolated SBCD [HBI = 7 (IQR 5-10) vs HBI = 6(IQR 4-9); P = 0.04 ]. There was no significant difference in the FC levels between isolated SBCD and ileocolonic disease [136ug/g (IQR 53.8-363.3) vs 171ug/g (IQR 68.5-485.5); p = 0.98]. In isolated SBCD group, 30.3 % (n = 54) CE showed proximal disease, 96 % (n = 171) showed distal disease and 26.4 % (n = 47) showed extensive disease. SBCE was superior to MRI at diagnosing proximal SBCD (P < 0.01). On multivariate logistic regression, we did not identify any predictors of disease severity defined as Lewis score > 790. Following SBCE, 68.5 % (n = 170) of the total patients had a management change. This included commencement or dose escalation of corticosteroids in 123 (49.5 %) patients, azathioprine in 80 (33.3 %) patients, methotrexate in 22 (9.1 %) patients and biological therapy in 110 (44.3 %) patients. HBI predicted a change in management (p < 0.01).

CONCLUSION

CE is an important modality for the diagnosis of active SBCD. It also helps guide treatment in patients identified with active disease.

Characteristics and prognosis of isolated small-bowel Crohn's disease

BACKGROUND

Previous studies suggest that Crohn's disease (CD) with both small bowel and colon involvement is more serious than colonic CD. However, clinical features of isolated small-bowel CD have not been fully investigated.

METHODS

In this retrospective case-control study, 89 patients were divided into two groups according to capsule endoscopy, ileocolonoscopy, and enhanced computed tomography results. The case group was isolated small-bowel CD (n = 50) and the control group was CD with both small bowel and colon involvement (n = 39). We collected data of the patients and analyze it.

RESULTS

In univariate analysis, isolated small-bowel CD group had higher percentage of stricture, Lewis score, platelet, plateletcrit and lower Harvey-Bradshaw index, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate. In multivariable analysis, it had lower Harvey-Bradshaw index (p = 0.000), which meaned relatively mild symptoms. However, it had higher Lewis score (p = 0.007), which meaned more serious small-bowel inflammation. The Kaplan-Meier survival curve also suggested that isolated small-bowel CD patients were more likely to accept partial small intestinal resection surgery (p = 0.029).

CONCLUSIONS

Isolated small-bowel CD is easily overlooked for milder clinical symptoms and relatively limited lessions, but severe small-bowel histological injury results in owing worse clinical outcomes. Clinicians should pay more attention to the isolated small-bowel CD and take aggressive intervention during therapy.

Long-term prognosis of the jejunal involvement of Crohn's disease

GOALS

We investigated the prognosis of Crohn's disease (CD) in Korean patients with jejunal involvement.

BACKGROUND

Although jejunal involvement is considered a poor prognostic factor of CD in whites, it has never been validated in Asian populations.

METHODS

We retrospectively reviewed the medical records of 1403 Korean CD patients (median age at diagnosis, 23 years; male patients, 72.3%; median follow-up duration, 65 mo). Probabilities of medication use, surgery, and hospitalization were analyzed by a Cox proportional hazards model and a Poisson regression model.

RESULTS

Jejunal involvement was observed in 198 of 1403 (14.1%) patients at diagnosis. There were more ileal location (28.3% vs. 20.6%, P<0.001) and stricturing behavior (16.7% vs. 9.4%, P=0.001) in the jejunal group than in the non-jejunal group. In univariate analyses, the cumulative probabilities of treatment with corticosteroids (P=0.014) and thiopurines (P=0.008), the first major surgery (P=0.021), and the first hospitalization (P=0.015) were significantly higher in the jejunal than in the non-jejunal group. In multivariate analyses, jejunal involvement was independently associated with the more common use of corticosteroids [hazard ratio, 1.24; 95% confidence interval (CI), 1.02-1.50] and thiopurines (hazard ratio, 1.26; 95% CI, 1.06-1.49), higher incidence rates of strictureplasties [relative risk (RR), 2.52; 95% CI, 1.60-3.96] and hospitalizations (RR, 1.29; 95% CI, 1.14-1.47), and longer hospitalization duration (RR, 1.30; 95% CI, 1.25-1.34).

CONCLUSIONS

Korean CD patients are more likely to have jejunal involvement than western patients. Jejunal involvement is one of the poor prognostic factors in Korean CD patients, as it is in westerners.

Relationship between proximal Crohn's disease location and disease behavior and surgery: a cross-sectional study of the IBD Genetics Consortium

OBJECTIVES

In classifying Crohn's disease (CD) location, proximal (L4) disease includes esophagogastroduodenal (EGD) and jejunal disease. Our aim was to determine the influence of proximal disease on outcomes of behavior and need for surgery and to determine if there was significant clinical heterogeneity between EGD and jejunal disease.

METHODS

We performed a cross-sectional query of the NIDDK (National Institute of Diabetes and Digestive and Kidney Disease) Inflammatory Bowel Disease Genetics Consortium (IBDGC) database of patients with a confirmed diagnosis of CD and phenotyped per the IBDGC manual. Presence of any L4, L4-EGD, L4-jejunal, and non-L4 disease (L1-ileal, L2-colonic, and L3-ileocolonic) was compared with demographic features including age, race, ethnicity, smoking and inflammatory bowel disease (IBD) family history, diagnosis age, disease duration, clinical outcomes of inflammatory, stricturing or penetrating behavior, and CD abdominal surgeries. Univariate and multivariable analyses were performed with R.

RESULTS

Among 2,105 patients with complete disease location data, 346 had L4 disease (175 L4-EGD, 115 L4-jejunal, and 56 EGD and jejunal) with 321 having concurrent L1-L3 disease. In all, 1,759 had only L1-L3 disease. L4 vs. non-L4 patients were more likely (P<0.001) to be younger at diagnosis, non-smokers, have coexisting ileal involvement, and have stricturing disease. L4-jejunal vs. L4-EGD patients were at least twice as likely (P<0.001) to have had ileal disease, stricturing behavior, and any or multiple abdominal surgeries. Remarkably, L4-jejunal patients had more (P<0.001) stricturing behavior and multiple abdominal surgeries than non-L4 ileal disease patients. Logistic regression showed stricturing risks were ileal (without proximal) site (odds ratio (OR) 3.18; 95% confidence interval 2.23-4.64), longer disease duration (OR 1.33/decade; 1.19-1.49), jejunal site (OR 2.90; 1.89-4.45), and older age at diagnosis (OR 1.21/decade; 1.10-1.34). Multiple surgery risks were disease duration (OR 3.74/decade; 3.05-4.64), penetrating disease (OR 2.60; 1.64-4.21), and jejunal site (OR 2.39; 1.36-4.20), with short duration from diagnosis to first surgery protective (OR 0.87/decade to first surgery; 0.84-0.90).

CONCLUSIONS

Jejunal disease is a significantly greater risk factor for stricturing disease and multiple abdominal surgeries than either EGD or ileal (without proximal) disease. The Montreal site classification should be revised to include separate designations for jejunal and EGD disease.

Manifestations of small bowel disease in pediatric Crohn's disease on magnetic resonance enterography

BACKGROUND

We report the manifestations of Crohn's disease (CD) observed on magnetic resonance enterography (MRE) in a pediatric population at the time of CD diagnosis.

METHODS

MRE of 95 consecutive pediatric patients with inflammatory bowel disease (IBD) examined in 2006-2009 were retrospectively analyzed, with documentation of findings based on type and location of the small bowel (SB) disease.

RESULTS

In all, 51 were boys and 44 girls. 54 had CD, 31 non-CD IBD, and 10 no IBD. The most common site of SB involvement in CD was the terminal ileum seen in 29 (53.7%) patients, followed by ileum in 10 (18.5%) and jejunum in 9 (16.7%) patients. Solitary jejunal inflammation (3.7%), SB stenoses (1.9%), fistula formation (0.95%), and abscess (0.95%) were much less common. Perienteric lymphadenopathy was seen in 30 (55.6%) patients and fatty proliferation in 9 (16.7%). The most common manifestation of SB inflammation was increased contrast enhancement of bowel wall (93.5%), thickening of the bowel wall (90.3%), and derangement of bowel shape with saccular formations (25.8%).

CONCLUSIONS

MRE in the pediatric population often demonstrates increased contrast uptake, bowel wall thickening, and perienteral lymphadenopathy in CD. More chronic small bowel changes seen commonly in adults and solitary jejunal involvements are less commonly seen.

Timing of surgery in Crohn’s disease: A key issue in the management

The timing of the decision for operation in Crohn’s disease is based on an evaluation of the several factors such as the failure of medical treatment, complications due to the Crohn’s disease or to the farmacological therapy, development of dysplasia or cancer and growth retardation. A complete evaluation of these factors should result in operation timed to the patient’s best advantage, achieving maximal relief of symptoms with improvement of quality of life. Given the complexity and heterogeneity of the disease and the different options for treatment, is difficult to systematize when the optimal moment for the surgery is arrived. A very important factor in the management of Crohn’s disease is the multidisciplinary approach and the patient preference should be a significant factor in determining the choice of therapy. The surgery should be considered such another option in the sequential treatment of Crohn’s disease. We have analyzed the factors that are involved in the decision taking of the surgical treatment regarding to the experience and the published literature. When did the medical therapy fail? when is the appropriate moment to operate on the patient? Or which complications of Crohn’s disease need a surgery? These are some of the questions we will try to answer.