Capsule endoscopy may reclassify pediatric inflammatory bowel disease: a historical analysis

Guidelines for endoscopic diagnosis and treatment of inflammatory bowel diseases

In recent years, we have seen a considerable increase in the number of patients with inflammatory bowel diseases of unknown etiology, including both Crohn's disease and ulcerative colitis. Inflammatory bowel diseases can cause intestinal lesions throughout the gastrointestinal tract, necessitating gastrointestinal endoscopy for examining all relevant aspects, especially lesion characteristics, for differential diagnosis and histological diagnosis, to select the appropriate treatment options, determine treatment effectiveness, etc. Specific guidelines are necessary to ensure that endoscopy can be performed in a safe and more tailored and efficient manner, especially since gastrointestinal endoscopy, including enteroscopy, is a common procedure worldwide, including in Japan. Within this context, the Japan Gastroenterological Endoscopy Society has formulated the "Guidelines for the Endoscopic Diagnosis and Treatment of Inflammatory Bowel Diseases" to provide detailed guidelines regarding esophagogastroduodenoscopy, enteroscopy, and colonoscopy procedures for definitive diagnosis, as well as determination of treatment effectiveness in clinical cases of inflammatory bowel diseases.

Endoscopy in Special Situations in Inflammatory Bowel Disease: Acute Colitis, Pregnancy, and Pediatrics

Endoscopy for a hospitalized patient with acute severe ulcerative colitis should be limited to flexible sigmoidoscopy. If, during pregnancy, inflammatory bowel disease (IBD) is active or if a new diagnosis of IBD is suspected, endoscopy may be needed to guide medical decision-making. The determination to proceed with endoscopy during pregnancy is nuanced and requires the ability to discern appropriate indications, knowledge regarding safety of bowel preparation and anesthesia. Pediatric patients with IBD represent a unique subset of IBD with distinctive diagnostic, therapeutic, and monitoring considerations.

Predictors of Small Bowel Transit Time for Capsule Endoscopy in Children with Inflammatory Bowel Disease

Purpose

The development of assistive devices has allowed for the performance of capsule endoscopy in children. Anticipating the capsule's transit time could affect the efficacy of the investigation and potentially minimize the fasting period. This study determined the predictors of small bowel transit time for small-bowel capsule endoscopy in children and adolescents with inflammatory bowel disease.

Methods

We retrospectively examined children and adolescents with inflammatory bowel disease who underwent capsule endoscopy by the age 18 at a Japanese tertiary care children's hospital. Small bowel transit time predictors were analyzed using multiple regression with explanatory variables.

Results

Overall, 92 patients, aged 1-17 years, with inflammatory bowel disease (63 Crohn's disease and 29 ulcerative colitis cases) were examined for factors affecting small bowel transit time. In the simple regression analysis, diagnosis, age, height, weight, serum albumin, general anesthesia, and small intestine lesions were significantly associated with small bowel transit time. In the multiple regression analyses, serum albumin (partial regression coefficient: -58.9, p=0.008), general anesthesia (partial regression coefficient: 127, p<0.001), and small intestine lesions (partial regression coefficient: 30.1, p=0.037) showed significant associations with small bowel transit time.

Conclusion

Hypoalbuminemia, the use of general anesthesia for endoscopic delivery of the capsule, and small intestine lesions appeared to be predictors of prolonged small bowel transit time in children and adolescents with inflammatory bowel disease. Expecting the finishing time may improve examination with a fasting period reduction, which benefits both patients and caregivers.

Capsule Endoscopy in Inflammatory Bowel Disease: When? To Whom?

Capsule endoscopy (CE) has proven to be a valuable diagnostic modality for small bowel diseases over the past 20 years, particularly Crohn's disease (CD), which can affect the entire gastrointestinal tract from the mouth to the anus. CE is not only used for the diagnosis of patients with suspected small bowel CD, but can also be used to assess disease activity, treat-to-target, and postoperative recurrence in patients with established small bowel CD. As CE can detect even mildly non-specific small bowel lesions, a high diagnostic yield is not necessarily indicative of high diagnostic accuracy. Moreover, the cost effectiveness of CE as a third diagnostic test employed usually after ileocolonoscopy and MR or CT enterography is an important consideration. Recently, new developments in colon capsule endoscopy (CCE) have increased the utility of CE in patients with ulcerative colitis (UC) and pan-enteric CD. Although deflation of the colon during the examination and the inability to evaluate dysplasia-associated lesion or mass results in an inherent risk of overestimation or underestimation, the convenience of CCE examination and the risk of flare-up after colonoscopy suggest that CCE could be used more actively in patients with UC.

Role of capsule endoscopy in inflammatory bowel disease: Anything new?

Capsule endoscopy (CE) is a recently developed diagnostic method for diseases of the small bowel that is non-invasive, safe, and highly tolerable. Its role in patients with inflammatory bowel disease has been widely validated in suspected and established Crohn’s disease (CD) due to its ability to assess superficial lesions not detected by cross-sectional imaging and proximal lesions of the small bowel not evaluable by ileocolonoscopy. Because CE is a highly sensitive but less specific technique, differential diagnoses that can simulate CD must be considered, and its interpretation should be supported by other clinical and laboratory indicators. The use of validated scoring systems to characterize and estimate lesion severity (Lewis score, Capsule Endoscopy Crohn’s Disease Activity Index), as well as the standardization of the language used to define the lesions (Delphi Consensus), have reduced the interobserver variability in CE reading observed in clinical practice, allowing for the optimization of diagnoses and clinical management strategies. The appearance of the panenteric CE, the incorporation of artificial intelligence, magnetically-guided capsules, and tissue biopsies are elements that contribute to CE being a promising, unique diagnostic tool in digestive tract diseases.

Capsule Endoscopy in Children

Since its clearance for use throughout the world, capsule endoscopy (CE) has become an important diagnostic tool, helping us to understand and document both normal and abnormal findings in the small intestine, especially in children, since CE usually can be employed without sedation or radiation. The indications in children and adults are similar, though their relative frequencies are different, with evaluation of potential and known inflammatory bowel disease the most common in the pediatric population, with CE also yielding increased diagnostic certainty compared to radiographic studies and surrogate biomarkers. Newer capsules now create opportunities to expand that understanding and our practices so that we can learn when and how to employ CE and pan-enteric CE to better monitor and guide therapy. It will take further studies to determine the best uses for CE and how to select the appropriate candidates, especially with ongoing concern about capsule ingestion vs. placement, the potential for capsule retention (particularly in known Crohn's disease), still elusive optimal methods for bowel cleansing, and the most meaningful scoring for research and clinical use.

Features and Outcomes of Children with Ulcerative Colitis who Undergo a Diagnostic Change: A Single-Center Experience

PURPOSE

A change in diagnosis from ulcerative colitis (UC) to Crohn's disease (CD) has been reported in pediatric inflammatory bowel disease; however, only a few clinical characteristics and predictors of this diagnostic change have been reported. We aimed to describe the clinical characteristics of patients with UC who underwent a change in diagnosis to CD and identify variables associated with the change.

METHODS

The medical records of pediatric patients with UC who were followed up at the National Center for Child Health and Development between 2006 and 2019 were retrospectively reviewed. Clinical data on disease phenotype, laboratory parameters, endoscopic findings, and treatment of patients whose diagnosis changed to CD (cCD) were compared to those of patients whose diagnosis remained UC (rUC).

RESULTS

Among the 111 patients initially diagnosed with UC, 11 (9.9%) patients were subsequently diagnosed with CD during follow-up. There was no significant difference between the cCD and rUC groups in terms of sex, age at initial diagnosis, and the extent and severity of disease at initial diagnosis. Albumin and hemoglobin levels were significantly lower in the cCD group than in the rUC group. The proportion of patients who required biologics was significantly higher in the cCD group than in the rUC group (p<0.05).

CONCLUSION

Approximately 10% children initially diagnosed with UC were subsequently diagnosed with CD. Hypoalbuminemia and anemia at initial diagnosis and use of biologics could be predictors of this diagnostic change.

The Cost-Effectiveness of Video Capsule Endoscopy

The development of video capsule endoscopy (VCE) has allowed for visualization of parts of the gastrointestinal tract generally not readily accessible by noninvasive means. Its ease of use has proved useful in diagnosing and managing various small bowel inflammatory disorders. Continued technological evolution of VCE has paved the way for use in small intestinal bleeding and in patients with acute gastrointestinal bleeding. A detailed analysis of costs associated with VCE has demonstrated its ability to promote efficient allocation of health care resources. Further work is needed regarding development of a universal infrastructure to handle the widespread use of VCE technology.

Ulcerative Colitis: Making the Diagnosis

Ulcerative colitis is an inflammatory condition of the colon. The diagnosis of ulcerative colitis is based on clinical presentation, endoscopic evaluation, and histologic parameters in the absence of demonstrable alternate etiology. The differential diagnosis remains broad, and infection in particular must be considered and excluded. Although laboratory and radiographic findings can aid in the diagnosis of ulcerative colitis, endoscopy remains the gold standard for diagnosis. A correct diagnosis and disease staging are imperative because these factors affect treatment options and prognosis.

Capsule Retention in Crohn's Disease: A Meta-analysis

BACKGROUND

The main factor that limits wider utilization of capsule endoscopy (CE) in Crohn's disease (CD) is the potential risk of retention. The aim of this systematic review was to evaluate capsule retention rates in adult and pediatric CD and determine if retention risk is reduced in established CD (ECD) with patency capsule (PC) or magnetic resonance/computed tomography (MR/CT) enterography.

METHODS

Studies of CD patients undergoing CE that reported retention were identified. Pooled estimates for retention rates and relative risk in ECD to suspected CD (SCD) were calculated. All hypothesis tests were 2-sided; statistical significance was set at a P value of <0.05.

RESULTS

In the overall CD cohort, retention rates were 3.32% (95% confidence interval [CI], 2.62%-4.2%): 4.63% (95% CI, 3.42%-6.25%) and 2.35% (95% CI, 1.31%-4.19%) in ECD and SCD, respectively. Retention rates were 3.49% (95% CI, 2.73%-4.46%) and 1.64% (95% CI, 0.68%-3.89%) in adult and pediatric CD, respectively. Retention risk in adult ECD was 3.4 times higher than SCD, but there was no difference in retention risk in pediatric ECD compared with SCD. Retention rates in ECD were decreased after patency capsule (2.88%; 95% CI, 1.74%-4.74%) and MR/CT enterography (2.32%; 95% CI, 0.87%-6.03%).

CONCLUSIONS

In comparison with older literature, this meta-analysis demonstrates lower CE retention rates in SCD and ECD. Retention rates in pediatric CD were lower than in adult CD. Retention rates in adult ECD were higher than SCD, but there were no differences between pediatric ECD and SCD. Retention rates in ECD were lower after negative PC or MR/CT enterography.

Capsule endoscopy: Current status and role in Crohn's disease

Capsule endoscopy (CE) has proved to be an important non-invasive tool for diagnosis and monitoring Crohn's disease patients. It has the advantage of excellent visualization of digestive tract mucosa, a good tolerability and safety in well-selected patients. The risk of retention can be diminished by good selection of patients using imaging techniques and by the use of patency capsule. The aim of a capsule examination is not only an early diagnosis but also a very good stratification of prognosis, thus directing the treatment strategy for either a step up or top-down approach and also permitting the optimization of the treatment depending on the findings. When symptoms and biomarkers point to a change in the disease's activity we can either adjust the treatment directly as recommended in CALM study or choose in selected patients to visualize the digestive mucosa through a CE and take a decision afterwards. The appearance of the new capsule from Medtronic-the Pillcam Crohn's might be an important step forward in diagnosis, evaluating disease extent, the severity of the disease, prognosis, management in a treat to target approach, with treatment modifications according to the data from CE examination. Serial examinations in the same patient can be compared and a more objective evaluation of the lesions modification from one exam to another can be performed. We present the latest developments and current status and evidence that in selected patients capsule can be a tool in a treat to target approach.

Endoscopy in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto IBD Group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition

Endoscopy is a central tool for the evaluation and management of inflammatory bowel disease (IBD). In the last few decades, gastrointestinal (GI) endoscopy has undergone significant technological developments including availability of pediatric-size equipment, enabling comprehensive investigation of the GI tract in children. Simultaneously, professional organization of GI experts have developed guidelines and training programs in pediatric GI endoscopy. This prompted the Porto Group on Pediatric IBD of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition to develop updated guidelines on the role of GI endoscopy in pediatric IBD, specifically taking into considerations of recent advances in the diagnosis, disease stratification, and novel therapeutic targets in these patients.

Guideline for wireless capsule endoscopy in children and adolescents: A consensus document by the SEGHNP (Spanish Society for Pediatric Gastroenterology, Hepatology, and Nutrition) and the SEPD (Spanish Society for Digestive Diseases)

INTRODUCTION

Capsule Endoscopy (CE) in children has limitations based mainly on age. The objective of this consensus was reviewing the scientific evidence.

MATERIAL AND METHODS

Some experts from the Spanish Society of Gastroenterology (SEPD) and Spanish Society for Pediatric Gastroenterology, Hepatology, and Nutrition (SEGHNP) were invited to answer different issues about CE in children. These sections were: a) Indications, contraindications and limitations; b) efficacy of CE in different clinical scenarios; c) CE performance; d) CE-related complications; e) Patency Capsule; and f) colon capsule endoscopy. They reviewed relevant questions on each topic.

RESULTS

The main indication is Crohn's disease (CD). There is no contraindication for the age and in the event that the patient not to swallow it, it should be administered under deep sedation with endoscopy and specific device. The CE is useful in CD, for the management of OGIB in children and in Peutz-Jeghers syndrome (in this indication has the most effectiveness). The main complication is retention, which should be specially taken into account in cases of CD already diagnosed with malnutrition. A preparation regimen based on a low volume of polyethylene glycol (PEG) the day before plus simethicone on the same day is the best one in terms of cleanliness although does not improve the results of the CE procedure.

CONCLUSIONS

CE is safe and useful in children. Indications are similar to those of adults, the main one is CD to establish both a diagnosis and disease extension. Moreover, only few limitations are detected in children.

Video capsule endoscopy in inflammatory bowel disease

Video capsule endoscopy (VCE) has evolved to become an important tool for the non-invasive examination of the small bowel, which hitherto had been relatively inaccessible to direct visualisation. VCE has been shown to play a role in monitoring the activity of small bowel Crohn’s disease and can be used to assess the response to anti-inflammatory treatment in Crohn’s disease. For those patients with Crohn’s disease who have undergone an intestinal resection, VCE has been assessed as a tool to detect post-operative recurrence. VCE may also aid in the reclassification of patients with a diagnosis of Inflammatory Bowel Disease Unclassified to Crohn’s disease. The evolution of colon capsule endoscopy (CCE) has expanded the application of this technology further. The use of CCE to assess the activity of ulcerative colitis has been described. This advance in capsule technology has also fuelled interest in its potential role as a minimally invasive tool to assess the whole of GI tract opening the possibility of its use for the panenteric assessment of Crohn’s disease. VCE is a safe procedure. However, the risk of a retained capsule is higher in patients with suspected or confirmed Crohn’s disease compared with patients having VCE examination for other indications. A retained video capsule is rare after successful passage of a patency capsule which may be utilised to pre-screen patients undergoing VCE. This paper describes the use of VCE in the assessment of inflammatory bowel disease.

Capsule Endoscopy for Ileitis with Potential Involvement of Other Sections of the Small Bowel

Ileitis is defined as inflammation of the ileum. This condition includes ulcers, aphthous ulcers, erosions, and nodular or erythematous mucosa. Various etiologies are associated with ileitis. Crohn's disease, ulcerative colitis, medications such as nonsteroidal anti-inflammatory drugs, infectious conditions, neoplasms, infiltrative disorders, vasculitides, spondyloarthritis, endometriosis, and radiation therapy-related conditions involve the ileum. However, the differential diagnosis of terminal ileitis can be difficult in many cases. Video capsule endoscopy (VCE) has become a useful tool for the diagnosis of a variety of small bowel lesions. This review describes each of the various conditions associated with ileitis and the diagnostic value of VCE for ileitis, which may help identify and evaluate these conditions in clinical practice. Based on the information provided by VCE, a definitive diagnosis could be made using the patients' medical history, clinical course, laboratory and ileocolonoscopic findings, radiologic imaging findings, and histologic findings.

Video Capsule Endoscopy of the Small Bowel for Monitoring of Crohn's Disease

Video capsule endoscopy has revolutionized our ability to visualize the small bowel mucosa. This modality is a valuable tool for the diagnosis of suspected small bowel Crohn's disease, and it is increasingly used for the monitoring of disease activity in patients with established small bowel Crohn's. The purpose of the current article was to review the literature pertaining to the utilization of capsule endoscopy in established Crohn's disease, for monitoring of mucosal healing, postoperative recurrence, disease classification, and other indications.

Particularities of Crohn's disease in pediatric patients: current status and perspectives regarding imaging modalities

A consensus on the best imaging modality evaluating inflammatory bowel disease in the pediatric population is lacking and it is often unclear which modality to choose in specific clinical circumstances. Children with inflammatory bowel disease are exposed to ionizing radiation from multiple imaging studies performed at initial diagnosis, throughout treatment and during the follow-up period. This paper discusses the value of different imaging techniques in pediatric patients with inflammatory bowel disease and gives a review of the literature. In addition, particular features of inflammatory bowel disease in children including the predilection of affected segments in the gastrointestinal tract are highlighted. Based on current literature knowledge, we encourage an integrative approach to the interpretation of clinical and imaging data for diagnosis and follow-up in daily clinical settings.

Role of wireless capsule endoscopy in the follow-up of inflammatory bowel disease

The introduction of wireless capsule endoscopy in 2000 has revolutionized our ability to visualize parts of the small bowel mucosa classically unreached by the conventional endoscope, and since the recent introduction of colon capsule endoscopy, a promising alternative method has been available for the evaluation of large bowel mucosa. The advantages of wireless capsule endoscopy include its non-invasive character and its ability to visualize proximal and distal parts of the intestine, while important disadvantages include the procedure’s inability of tissue sampling and significant incompletion rate. Its greatest limitation is the prohibited use in cases of known or suspected stenosis of the intestinal lumen due to high risk of retention. Wireless capsule endoscopy plays an important role in the early recognition of recurrence, on Crohn’s disease patients who have undergone ileocolonic resection for the treatment of Crohn’s disease complications, and in patients’ management and therapeutic strategy planning, before obvious clinical and laboratory relapse. Although capsule endoscopy cannot replace traditional endoscopy, it offers valuable information on the evaluation of intestinal disease and has a significant impact on disease reclassification of patients with a previous diagnosis of ulcerative colitis or inflammatory bowel disease unclassified/indeterminate colitis. Moreover, it may serve as an effective alternative where colonoscopy is contraindicated and in cases with incomplete colonoscopy studies. The use of patency capsule maximizes safety and is advocated in cases of suspected small or large bowel stenosis.

Wireless capsule endoscopy of the small intestine in children

Wireless capsule endoscopy (CE) for the diagnosis of small-bowel disease has been in clinical use for more than a decade, and is no longer an emerging technology, but rather one that has reached fruition. This noninvasive technology has been readily embraced by both physicians and patients. Used in the diagnosis of inflammatory bowel disease, for locating sources of obscure gastrointestinal bleeding, and for assessing small-bowel polyp burden in polyposis syndromes as well as for less common indications, CE has transformed the diagnostic algorithms of small-bowel investigations. Although already in widespread use, the technology incorporated into the various CE platforms continues to improve and expand. Here, we briefly review the indications, limitations, and advances in video capsule technology, with an emphasis on its use in pediatrics.

Capsule endoscopy in pediatrics: a 10-years journey

Video capsule endoscopy (CE) for evaluation the esophagus (ECE), small bowel (SBCE) and the colon (CCE) is particularly useful in pediatrics, because this imaging modality does not require ionizing radiation, deep sedation or general anesthesia. The risk of capsule retention appears to be dependent on indication rather than age and parallels the adult experience by indication, making SBCE a relatively safe procedure with a significant diagnostic yield. The newest indication, assessment of mucosal change, greatly enhances and expands its potential benefit. The diagnostic role of CE extends beyond the SB. The use of ECE also may enhance our knowledge of esophageal disease and assist patient care. Colon CCE is a novel minimally invasive and painless endoscopic technique allowing exploration of the colon without need for sedation, rectal intubation and gas insufflation. The limited data on ECE and CCE in pediatrics does not yet allow the same conclusions regarding efficacy; however, both appear to provide safe methods to assess and monitor mucosal change in their respective areas with little discomfort. Moreover, although experience has been limited, the patency capsule may help lessen the potential of capsule retention; and newly researched protocols for bowel cleaning may further enhance CE's diagnostic yield. However, further research is needed to optimize the use of the various CE procedures in pediatric populations.

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.

Role of wireless capsule endoscopy in reclassifying inflammatory bowel disease in children

OBJECTIVE

To evaluate the role of wireless capsule endoscopy in identifying small bowel lesions in pediatric patients with newly diagnosed colonic inflammatory bowel disease (IBD) type unclassified (IBDU), and to assess whether capsule endoscopy findings result in altered patient management.

METHODS

Ten pediatric patients recently diagnosed with IBDU through standard investigations were recruited from the pediatric gastroenterology clinic at McMaster Children's Hospital to undergo capsule endoscopy using the Pillcam SB(TM) (Given Imaging) capsule. Findings consistent with a diagnosis of Crohn's disease required the identification of at least three ulcerations.

RESULTS

Three out of ten patients had newly identified findings on capsule endoscopy that met criteria for Crohn's disease. Three more patients had findings suspicious for Crohn's disease, but failed to meet the diagnostic criteria. Three additional patients had findings most consistent with ulcerative colitis, and one had possible gastritis with a normal intestine. Findings from capsule endoscopy allowed for changes in the medical management of three patients. In all ten cases, capsule endoscopy allowed for a better characterization of the type and extent of disease. No adverse outcomes occurred in the present cohort.

CONCLUSION

This prospective study reveals that wireless capsule endoscopy is feasible, valuable, and non-invasive, offering the ability to potentially better characterize newly diagnosed pediatric IBDU cases by identifying lesions in the small bowel and reclassifying these as Crohn's disease.

New vision in video capsule endoscopy: current status and future directions

Now, more than 10 years after the approval of video capsule endoscopy (VCE), the technology has become an essential component in the management of several clinical conditions. Currently, two capsules are approved in the USA for visualizing the small bowel mucosa, one capsule is authorized for oesophageal assessment and several others are in use or under evaluation worldwide. New investigations have focused on optical improvements, advances in intestinal cleansing and risk reduction strategies to optimize VCE methodologies in clinical care. Established indications diagnosed using VCE include unexplained gastrointestinal bleeding, small bowel Crohn's disease (in adults and children >10 years old), localization of small bowel tumours and a broad range of miscellaneous abnormalities. Investigations are ongoing to determine the utility of VCE in colon cancer screening, assessment of oesophageal disorders and diagnosis of coeliac disease. Active research is in progress into ways to improve the efficacy of VCE recording interpretation, prolong imaging time and further enhance optics and imaging methods. To expand the potential utility of VCE, novel devices that can manoeuvre within or insufflate the gut lumen, tag or biopsy suspect lesions, or target drug delivery to specific sites are in development. To facilitate these advances, consortia have been organized to promote innovative VCE technologies.

Pediatric capsule endoscopy: review of the small bowel and patency capsules

BACKGROUND AND OBJECTIVE

Because capsule endoscopy (CE) avoids ionizing radiation, deep sedation, and general anesthesia, CE may be valuable in pediatrics. We report a single pediatric center's experience with the use and safety of CE.

METHODS

In a retrospective review of consecutive CE studies, 284 CE studies were performed in 277 patients with a mean age of 15 (±3.7) years during a 5-year period. The youngest to swallow the capsule was 4.6 years old. Twenty capsules were placed. Overall, 245 (86%) patients underwent CE for suspected (184, 65%) or confirmed (61, 21%) Crohn disease (CD); 27 (9.5%) anemia or gastrointestinal bleeding; 6 (2%) polyposis; and 4 (1.4%) celiac disease.

RESULTS

Positive findings were observed in 205 (72%) of the studies, with 152 (54%) having small bowel findings. Of these, 72 (47%) were diagnostic. Gastric (95, 33%) and colonic (31, 11%) abnormalities were also identified. Five CE studies (1.8%) resulted in retention of the capsule in nonsurgical patients. A patency capsule before CE in 23 patients allowed 19 CE to proceed with only 1 retained capsule. In 65 (21%) patients, the video capsule did not enter the colon before the video's end. Of these, 36 (65%) had significant findings, including 27 (49%) documenting small bowel (SB) CD.

CONCLUSIONS

CE is useful to diagnose SB disease in children. Even in a study population with a high prevalence of confirmed and suspected CD, the risk of retention remains small. The patency capsule may lessen that risk. CE may identify gastric or colonic disease even when SB lesions are not present.

Small bowel capsule endoscopy impacts diagnosis and management of pediatric inflammatory bowel disease: a prospective study

PURPOSE

Accurately classifying inflammatory bowel disease (IBD) type in pediatric patients may impact medical decision-making, direct therapy, and improve outcomes.

METHODS

This was a prospective cohort study evaluating classification of IBD and patient management with use of capsule endoscopy in pediatric patients with suspected or known IBD. Treating physicians completed a questionnaire before and after capsule endoscopy (CE) assessing clinical suspicion of Crohn's disease (CD) diagnosis, patient management decisions, and perceived impact of CE findings.

RESULTS

Eighteen subjects [11F/7M, mean age 13.8 (± 2.5) years], 4 previously diagnosed with CD, 4 with ulcerative or indeterminate colitis (UC/IC), and 10 "suspected" to have IBD were included. Following CE, 2 of 4 (50%) UC/IC patients were reclassified as having small bowel CD. In the 4 subjects with known CD, 2 (50%) had CE evidence of more proximal small bowel mucosal disease than previously recognized. In the 10 subjects with "suspected" IBD, 8 (80%) had SB ulcerations leading to a definitive diagnosis of CD. Treating physicians reported CE helped diagnosing CD in 15 of 18 (83.3%) subjects and impacted medical decision-making in 13 of 18 (72.2%), leading to a change in medical management in 14 of 18 (77.8%).

CONCLUSIONS

In "suspected" pediatric IBD, CE often leads to a definitive diagnosis of CD. CE can lead to reclassification of IBD from UC/IC to CD and previously diagnosed CD patients may have a more significant burden of small bowel disease. These data may help integrate CE in evaluating IBD patients, lead to more targeted medical management changes and improve outcomes.

Enteroscopy in children

PURPOSE OF REVIEW

Endoscopic investigation of small bowel disorders in children has historically been difficult due to the length and tortuosity of the organ itself. New technology introduced over the past decade allows minimally invasive, detailed endoscopic evaluation of the small bowel mucosa from the duodenum to the cecum. While understudied in the pediatric population, literature is emerging supporting the use of these techniques and devices in children.

RECENT FINDINGS

Well tolerated and clinically useful capsule endoscopy has been reported a number of times in children, and the indications and potential complications of this procedure are discussed. The limitations of capsule endoscopy, namely inability to biopsy and treat small bowel lesions, have been addressed to some extent by the introduction of balloon enteroscopy, which allows deep intubation of the small bowel, and at times viewing of the entire mucosal surface. Balloon enteroscopy has been safely reported in children as small as 13.1  kg, and has been successfully performed in children with Roux-en-Y anastomoses in the evaluation and therapy of biliary strictures.

SUMMARY

New enteroscopic techniques now allow detailed investigation and therapy of small bowel lesions in a minimally invasive fashion in the pediatric population.

Use of capsule endoscopy in diagnosis and management of pediatric patients, based on meta-analysis

BACKGROUND & AIMS

To further our understanding of capsule endoscopy (CE) in children, we systematically compiled data on indications and outcomes and evaluated the effectiveness of CE on patient management using meta-analyses.

METHODS

We searched the Medline and PubMed databases (January 2001-May 2010) for English language citations of use of CE in patients ≤18 years old. Duplicate reports and those that included 5 patients or fewer were removed. We analyzed data from 15 source documents with 740 CE procedures in 723 patients.

RESULTS

Suspicion or evaluation of inflammatory bowel diseases was the most common indication for CE (54%: 34% for patients suspected to have Crohn's disease [CD], 16% for patients known to have CD, 1% for patients with ulcerative colitis, and 3% for patients with indeterminate colitis). Completion and retention rates were 86.2% (95% confidence interval [CI], 81.5-90.3) and 2.6% (95% CI, 1.5-4.0), respectively. Retention rates for children that underwent gastric (0.5%) or small bowel (1.9%) CE were similar to those of adults, by indication. For CE, 65.4% of procedures resulted in positive findings (95% CI, 54.8-75.2). Where reported, 69.4% of CE examinations (95% CI, 46.9-87.9) resulted in a new diagnosis and 68.3% (95% CI, 43.6-88.5) led to change in therapy.

CONCLUSIONS

The relative frequency of CE indications varies among pediatric and adult patients. In pediatric patients, CE is used primarily to evaluate patients with CD - to aid in diagnosis, monitor disease severity, and assist patient management. Retention rates appear to be related to indication, rather than patient age; capsule retention is relatively infrequent for adults and children.

Usefulness of wireless capsule endoscopy in paediatric inflammatory bowel disease

BACKGROUND

Small bowel endoscopy is critical in revealing an inflammatory bowel disease (IBD) previously undetected and in classifying the IBD patients, i.e. Crohn's disease or ulcerative colitis.

METHODS

A prospective paediatric study on the usefulness of wireless capsule endoscopy (WCE) was performed in 117 children (age range: 4-17 years) with established or suspected IBD and compared with non endoscopic imaging tools. All patients underwent upper and lower gastrointestinal endoscopy.

RESULTS

In Crohn's disease patients (CD, n=44), small bowel lesions were revealed by imaging tools in 8 and by WCE in 18 patients, respectively (p<0.01). No small bowel involvement was observed in 29 ulcerative colitis patients by both imaging tools and WCE. Of 26 unclassified IBD, small bowel lesions typical of Crohn's disease were detected by imaging in 7 and by WCE in 16 (p<0.05). Of 18 patients with suspected IBD, small bowel lesions typical of Crohn's disease were observed in 9 with WCE, vs. only in 4 with imaging (p<0.01). No cases of capsule retention occurred.

CONCLUSIONS

WCE is valuable in revealing small bowel lesions in children with a previous diagnosis of CD and unexplained clinical and laboratory data. It is also helpful in unclassified IBD patients. This tool can influence the management and the course of IBD.

The use of a patency capsule in pediatric Crohn's disease: a prospective evaluation

BACKGROUND

Capsule endoscopy (CE) retention remains a concern in patients with suspected or known Crohn's Disease (CD).

AIM

The aim of this study was to evaluate the ability of a patency capsule (PC) to establish functional patency in pediatric patients with suspected or known, symptomatic IBD.

METHODS

A prospective, single center study evaluating the impact of CE on CD management used PC to qualify patients for CE. Patients excreting an intact PC, usually within 40 h of ingestion, were able to undergo standard video CE. Excretion time, structural integrity and patient safety were evaluated.

RESULTS

Eighteen patients (10-16 years of age; 9 male; 5 known CD, 3 indeterminate colitis, 1 ulcerative colitis, 9 suspected CD) ingested the PC. Fifteen patients excreted intact PC (mean 34.5 h), 12 patients within 40 h (range 9-60 h). Sixteen (89%) underwent subsequent CE successfully. CD was eventually diagnosed in all patients having PC transit ≥40 h, whereas CD was the diagnosis in 9/12 (75%) in those patients who passed the PC within 40 h. The mean time of passage for an intact PC was 34.7 h, the longest 60 h. There were no capsule retentions or adverse events.

CONCLUSIONS

The PC appears to be a useful screening tool for functional patency of the small bowel in suspected or known pediatric CD. Delayed passage of an intact PC requires careful interpretation.

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.

Capsule endoscopy performed across the pediatric age range: indications, incomplete studies, and utility in management of inflammatory bowel disease

BACKGROUND

Capsule endoscopy (CE) is used increasingly to evaluate the small bowel in children. An upper GI series is recommended before CE to evaluate the risk of obstruction. Despite normal findings on an upper GI series, CE may still be incomplete. Although large adult studies have demonstrated the safety and diagnostic yield of CE, similar pediatric studies have not been available.

OBJECTIVE

To identify factors associated with incomplete studies and the diagnostic yield in pediatric patients.

DESIGN

Retrospective review of consecutive CE studies from February 2005 through June 2008.

SETTING

Large tertiary children's hospital.

PATIENTS

A total of 123 CE studies in 117 patients; median age 12.9 years (range 0.8-22.4 years).

MAIN OUTCOME MEASUREMENTS

Demographic information, indication, placement technique, pre-CE imaging results, and cecal completion status were recorded. Risk factors were analyzed with bivariate and multivariate regression analysis.

RESULTS

There were 27 (22%) incomplete studies; of these, there were normal pre-CE radiologic study findings in 12 (44%), and findings requiring medical, endoscopic, or operative intervention in 6. Of the 117 patients, CE produced a new diagnosis in 21 (18%). Abnormal findings on previous imaging (odds ratio [OR] 3.0; 95% CI, 1.2-8.0), endoscopic placement (OR 3.1; 95% CI, 1.1-8.4), and female sex (OR 3.3; 95% CI, 1.2-9.4) were associated with incomplete studies.

LIMITATIONS

Retrospective, incomplete follow-up.

CONCLUSIONS

CE may be performed in children as small as 11.5 kg, with 18% yield in all studies, and 28% in pediatric known inflammatory bowel disease. Capsule retention requiring retrieval did not pose life-threatening risk in our series, and CE may be used to identify disease-associated small-bowel stenosis.

Video capsule endoscopy in inflammatory bowel disease: past, present, and future redux

Over the last 8 years, capsule endoscopy (CE) has revolutionized the visualization of the small bowel. In 2004 this journal published "Capsule endoscopy in IBD: past, present and future" Kornbluth et al [2004] Inflamm Bowel Dis 10:278-285). In this article we review advances since that time and discuss whether CE has achieved its potential and what remaining goals it can and should hope to achieve. In the 2004 article we listed a series of clinical questions to be answered with regard to the use of capsule endoscopy We review those questions that have been addressed in the intervening 5 years, and also update those topics for which information was available at the time of the initial article.

Safety and efficacy of double-balloon enteroscopy in pediatric patients

BACKGROUND

Although double-balloon enteroscopy (DBE) is performed increasingly often in adults, few findings are available on the use of DBE in pediatric patients in the published literature.

OBJECTIVES

The aim of our study was to evaluate the safety and efficacy of DBE in pediatric patients.

DESIGN

A retrospective database review.

SETTING AND PATIENTS

A database analysis was performed on all pediatric patients (18 years old or younger) who underwent DBE at the Jichi Medical University Hospital between September 2000 and October 2008 selected from a total of 825 patients.

MAIN OUTCOME MEASUREMENTS

Clinical utility and safety of DBE in pediatric patients.

RESULTS

A total of 92 procedures were performed in 48 patients (27 male, 21 female) with a median age (range) of 12.2 (4-18) years. DBE was performed with the patients under general anesthesia in 43 procedures and under moderate sedation in 49 procedures. The most common indication for DBE was treatment of a stricture of a biliary anastomosis after living-donor liver transplantation with establishment of Roux-en-Y hepaticojejunostomy (23 patients). Endoscopic retrograde cholangiography using DBE was performed, and endoscopic therapy could be performed successfully in 13 (56%) patients. The second most common indication was obscure GI bleeding (10 patients); the lesions responsible for the bleeding were found in 7 (70%) patients. Other indications included surveillance and treatment of hereditary polyposis syndromes (5 patients), abdominal pain (4 patients), and inflammatory bowel disease (2 patients). The overall diagnostic yield was 65% (31 of the 48 patients). Postpolypectomy bleeding occurred in 1 case, but no other complications such as perforation and pancreatitis were observed.

LIMITATIONS

Small number of patients, participation bias, and single center's experience.

CONCLUSIONS

DBE is a safe and clinically useful endoscopic procedure in pediatric patients.

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.

Can ileal pouch anal anastomosis be used in Crohn's disease?

Restorative proctocolectomy with IPAA is now accepted as the standard of care in most patients with a diagnosis of mucosal ulcerative or IndC requiring surgery. In patients with Crohn's colitis needing intervention, proctocolectomy with end ileostomy or subtotal colectomy with ileorectal anastomosis is still the treatment of choice. In the authors' institution they consider performing an ileal pouch for a diagnosis of Crohn's colitis requiring rectal resection provided there is no existing or previous evidence of perianal or small bowel CD. They only perform this in a well-motivated patient who understands the potential sequelae, including an increased incidence of adverse effects and reduced functional outcome, if they develop CD of the pouch. A significant amount of time must be allocated to the patient and their family when counseling them with regards to the potential surgical options and outcomes associated with each. The development of CD of the pouch is associated with a considerable pouch failure rate requiring pouch excision or indefinite ileostomy formation. It does not always herald disaster, however, and a large percentage of patients can be salvaged using a combination of medical and surgical therapy. In this patient group the maintenance of intestinal continuity and avoidance of an ostomy is often the most important factor in their perception toward quality of life. The search for a serologic or genetic marker that will predict disease outcome in this select patient group and thereby direct surgical decision making should continue. It is recommended that in the presence of Crohn's colitis the decision to perform an ileal pouch should only be made in a tertiary center under the care of gastroenterologists, histopathologists, and colorectal surgeons with experience in the management of these complex cases.

Risk of capsule endoscope retention in pediatric patients: a large single-center experience and review of the literature

OBJECTIVES

Capsule retention is a potential complication of capsule endoscopy (CE). The aims of our study were to determine the incidence of capsule retention in pediatric patients undergoing CE and to identify potential risk factors for capsule retention.

MATERIALS AND METHODS

We performed an institutional review board-approved retrospective chart review of pediatric patients undergoing CE studies at a single center. Data collected included patient age, sex, prior diagnosis of inflammatory bowel disease (IBD), CE indication, prior small bowel series results, study result, and complications.

RESULTS

Two hundred seven CE procedures were performed in pediatric patients during the study period. Capsule retention occurred in 3 (1.4%) of the 207 studies. All 3 patients had known Crohn disease (CD). The risk of capsule retention in pediatric patients with known IBD was 5.2% (3/58). The risk of capsule retention for patients with suspected IBD and all other indications was 0%. If small bowel disease was identified on upper gastrointestinal series in patients with known CD, then the risk of capsule retention was 37.5% (3/8). Only 7 patients with known IBD had a body mass index (BMI) below the 5th percentile. Of these 7 patients, 3 (43%) had capsule retention.

CONCLUSIONS

Red flags for potential CE retention identified in our study include known IBD (5.2% retention risk), previous small bowel follow-through demonstrating small bowel CD (37.5% retention risk), and BMI <5th percentile with known IBD (43% retention risk). Caution is advised in these pediatric patients before capsule ingestion.