Panenteric capsule endoscopy identifies proximal small bowel disease guiding upstaging and treatment intensification in Crohn's disease: A European multicentre observational cohort study

Pan-enteric Capsule Endoscopy to Characterize Crohn's Disease Phenotypes and Predict Clinical Outcomes in Children and Adults: The Bomiro Study

BACKGROUND

Pan-enteric capsule endoscopy (PCE) provides useful information for the management of Crohn's disease (CD), especially in children. No study has evaluated the ability of PCE to characterize CD phenotypes and outcomes in children and adults.

METHODS

In a prospective multicenter observational study, we recruited patients with CD >6 years from 4 centers in Italy. Patients underwent clinical, biomarker assessment and PCE. Lesions were graded using the PCE system. For each segment, the most common lesion (MCL), the most severe lesion (MSL), and the extent of involvement were defined. Disease severity, extent, and clinical outcomes were compared between children and adults. A logistic regression analysis was used to identify predictive factors for negative outcomes in both age groups.

RESULTS

One hundred ninety-four consecutive patients (adults/children: 144/50) were evaluated for a total of 249 procedures. Children were more likely to have extensive disease, particularly in the colon. Higher MCL scores were independently associated with treatment escalation (odds ratio [OR], 4.09; 95% CI, 1.80-9.25; P = .001), while >30% disease extent was more indicative of clinical and endoscopic relapse (OR, 2.98; 1.26-7.08; P = .013). Disease extent was the only factor associated with endoscopic recurrence in children (OR, 4.50; 95% CI, 1.47-13.77; P = .008), while severe lesions in adults provided a better predictor of treatment escalation (OR, 4.31; 95% CI, 1.52-12.1; P = .006). Postexamination, PCE contributed to a change of therapy in 196/249 (79%) of the procedures.

CONCLUSIONS

PCE allowed the characterization of CD phenotypes in children and adults by assessing disease severity and extent, which are of different importance in predicting clinical outcomes in these age groups.

Small bowel Crohn's disease: Proximal lesions linked to increased inflammation and biologic treatment needs

OBJECTIVE

Crohn's disease (CD) is heterogeneous, and proximal involvement in the small bowel (SB) is associated with worse outcomes. Nonetheless, studies on the impact of duodenal and jejunal lesions in SB CD are limited. This study aimed to investigate the clinical characteristics and outcomes of individuals diagnosed with SB CD, comparing those with and without proximal inflammation.

METHODS

A cohort of 53 treatment-naive SB CD patients that underwent Capsule Endoscopy at diagnosis were retrospectively selected. The inflammatory activity was quantified using the Lewis Score for each SB tertile.

RESULTS

Thirty-seven (69.8%) patients displayed inflammatory activity in the first and/or second tertile together with third tertile involvement (Proximal+T3 group). Sixteen (30.2%) had inflammation in the third tertile only (T3 group). Individuals in the Proximal+T3 group had a higher risk for moderate-to-severe inflammation (OR 4.93, 95% CI: 1.3-18.3, p=0.013). A subgroup analysis for those with mild inflammatory activity showed that individuals in the Proximal+T3 group initiated biologic drugs more often (OR 11, 95% CI: 1.1-109.7, p=0.036).

CONCLUSION

Proximal SB lesions are associated with increased inflammatory activity, necessitating more frequent use of biologics in patients with mild disease. Early detection of proximal SB CD with Capsule Endoscopy may contribute to timely treatment.

Changes in Endoscopic Activity and Classification of Lesions With Panenteric Capsule Endoscopy in Patients Treated for Crohn's Disease-A Prospective Blinded Comparison With Ileocolonoscopy, Fecal Calprotectin, and C-Reactive Protein

BACKGROUND AND AIMS

Panenteric capsule endoscopy (PCE) is a minimally invasive modality that may replace ileocolonoscopy (IC) in selected patients with Crohn's disease (CD). This study aimed to evaluate the dynamics of repeated assessment with PCE in patients receiving medical treatment for ileocolonic CD.

METHODS

This prospective, blinded, multicenter study included patients with endoscopically active CD. Patients were scheduled for IC, PCE, fecal calprotectin, and C-reactive protein before and 12 weeks after treatment with corticosteroids or biological therapy. The endoscopic disease activity was assessed with the Simple Endoscopic Score for Crohn's Disease (SES-CD).

RESULTS

Thirty-one patients entered the study, and PCE visualized 148 (95.5%) and 128 (82.6%) ileocolonic bowel segments before and after medical treatment, respectively. The median SES-CD decreased from 14 (interquartile range [IQR] 8-17) to 5 (IQR 0-14) (p < 0.001) and 14 (IQR 10-17) to 6 (IQR 3-12) (p < 0.001) with IC and PCE, respectively. The repeated measures correlation between PCE and IC was very strong (r = 0.77, p < 0.001), strong compared to fecal calprotectin (r = 0.42, p = 0.003), and moderate compared to C-reactive protein (r = 0.36, p = 0.005). The mean scores for ulcer size, ulcerated surface, and affected surface were comparable between PCE and IC both before and after treatment. PCE had a sensitivity and specificity of 80.6% (95% confidence interval [95% CI] 62.5-92.5) and 93.8% (95% CI 79.2-99.2), respectively, for ulcer healing compared to IC.

CONCLUSIONS

PCE is responsive in patients treated for CD and may serve as a minimally invasive alternative to IC in selected patients.

Capsule Endoscopy in Inflammatory Bowel Disease: Evolving Role and Recent Advances

Capsule endoscopy has been proven as an efficient and accurate tool in the diagnosing and monitoring patients with inflammatory bowel disease, especially Crohn's disease (CD). The current European Crohn's and Colitis Organization guidelines recommend small bowel disease assessment in newly diagnosed CD, wherein small bowel capsule endoscopy (SBCE) is of prime importance. SBCE plays an essential role in assessing mucosal healing in patients with CD, serving as a monitoring tool in a treat to target strategy, and is capable of identifying high-risk patients for future flares.

Assessment of Treatment Response in Known Crohn's Disease-A Prospective Blinded Study Comparing the Diagnostic Accuracy of Intestinal Ultrasound, Magnetic Resonance Enterocolonography, Panenteric Capsule Endoscopy, and Fecal Calprotectin

BACKGROUND

Minimally invasive modalities may replace ileocolonoscopy (IC) in the follow-up of Crohn's disease (CD). The aim of this study was to evaluate intestinal ultrasound (IUS), magnetic resonance enterocolonography (MREC), panenteric capsule endoscopy (PCE), and fecal calprotectin (FC) for determining response to medical treatment in patients with ileocolonic CD.

METHODS

This prospective, blinded, multicenter study included patients with endoscopically active CD. Patients were scheduled for IC, MREC, IUS, PCE, and FC before and 12 weeks after treatment with corticosteroids or biological therapy. A ≥50% reduction of the Simple Endoscopic Score for Crohn's Disease (SES-CD) with IC defined treatment response.

RESULTS

Fifty patients completed the pre- and posttreatment evaluation with IC, and endoscopic response was achieved in 25 (50.0%). PCE was omitted in 12 (24.0%) patients because of stricturing CD. All activity scores decreased in patients achieving endoscopic response: The Simple Ultrasound Score for Crohn's Disease 2.2 vs 6.1 (P < .001), Magnetic Resonance Index of Activity 29.0 vs 37.1 (P = .05), SES-CD with PCE 3.1 vs 12.8 (P < .001), and FC 115.3 vs 1339.9 mg/kg (P < .001). The sensitivity and specificity of IUS, MREC, PCE, and FC were 80.0% (95% CI, 56.3-94.3)/77.8% (95% CI, 52.4-93.6), 65.2% (95% CI, 42.7-83.6)/87.0% (95% CI, 66.4-97.2), 87.5% (95% CI, 61.7-98.4)/86.7% (95% CI, 59.5-98.3), and 90.0% (95% CI, 68.3-98.8)/86.4% (95% CI, 65.1-97.1), respectively.

CONCLUSIONS

IUS and FC are equally effective for determining treatment response in patients with active CD. PCE is limited by the occurrence of strictures in this group of patients.

Pan-Enteric Crohn's Capsule [Eliakim] Score Reliability and Responsiveness to Change in Active Crohn's Disease

BACKGROUND AND AIMS

Pan-enteric capsule endoscopy (PillCam Crohn's capsule [PCC]) is a useful tool in diagnosing and monitoring Crohn's disease [CD]. Eliakim score [ES] reliability and its strong correlation to Lewis score [LS] and to inflammatory biomarkers have been previously demonstrated using PCC in quiescent CD. We aimed to examine ES performance in active CD and its responsiveness to clinical/biochemical change over time.

METHODS

Patients with CD who have started biologics were included, and were prospectively followed based on clinical visits, biomarkers, and PCC at baseline, after 14 and 52 weeks. Crohn's disease activity index [CDAI], C-reactive protein [CRP], and faecal calprotectin [FC] levels were determined, and LS and ES were calculated [independently reviewed by two experienced readers]. Inter-class classification [ICC], Spearman's baseline correlation, and repeated-measures correlation [RMC] analyses were performed.

RESULTS

Seventy-four patients were included (age: 30.5 [range 23.3-45.0] years old, male 50%). In total, 142 PCCs were read [baseline, 62; week 14, 58; week 52, 22]. Inter-rater agreement was high for both LS and ES (ICC: 0.872 [p < 0.001] and 0.925 [<0.001], respectively). Baseline correlations between FC&ES [r = 0.509 [p < 0.001]) and FC&LS (r = 0.467 [p < 0.001]) were comparable [p = 0.56]. RMCs between the inflammatory biomarkers and ES were higher than between the former and LS (Reader 1: CRP r = 0.306 vs r = 0.138 [p = 0.057], FC r = 0.479 vs r = 0.297 [p = 0.034]; Reader 2 CRP r = 0.376 vs r = 0.204 [p = 0.035], FC r = 0.549 vs r = 0.412 [p = 0.075]). Moreover, ES was better correlated to CDAI than LS [p = 0.036].

CONCLUSIONS

ES is a reliable scoring system in assessing pan-enteric mucosal inflammation in active CD, and might have a better responsiveness to clinical/biochemical change over time compared to LS.

A Comprehensive Review of Artificial Intelligence and Colon Capsule Endoscopy: Opportunities and Challenges

Colon capsule endoscopy (CCE) enables a comprehensive, non-invasive, and painless evaluation of the colon, although it still has limited indications. The lengthy reading times hinder its wider implementation, a drawback that could potentially be overcome through the integration of artificial intelligence (AI) models. Studies employing AI, particularly convolutional neural networks (CNNs), demonstrate great promise in using CCE as a viable option for detecting certain diseases and alterations in the colon, compared to other methods like colonoscopy. Additionally, employing AI models in CCE could pave the way for a minimally invasive panenteric or even panendoscopic solution. This review aims to provide a comprehensive summary of the current state-of-the-art of AI in CCE while also addressing the challenges, both technical and ethical, associated with broadening indications for AI-powered CCE. Additionally, it also gives a brief reflection of the potential environmental advantages of using this method compared to alternative ones.

The Role of Small-Bowel Capsule Endoscopy in the Diagnostic Algorithm of Complicated Perianal Disease

INTRODUCTION

Complicated perianal disease (cPD) may be the sole presentation of Crohn's disease (CD). The role of small-bowel capsule endoscopy (SBCE) in the diagnostic algorithm of cPD is unclear. We aimed to evaluate the role of SBCE as a diagnostic tool, in patients with cPD, after a negative standard workup for CD.

METHODS

A multicenter, retrospective, cross-sectional study, in patients with cPD, and negative standard workup for CD (ileocolonoscopy and cross-sectional imaging), who underwent SBCE for suspected CD. Demographics, biomarkers, and the Lewis Score (LS) were recorded and analyzed. An LS ≥ 135 was considered a positive SBCE for diagnosing CD.

RESULTS

Ninety-one patients were included: 65 (71.4%) males; median age: 37 (29-51) years; cPD duration: 25.1 (12.5-66.1) months. Positive SBCE: 24/91 (26.4%) patients. Fecal calprotectin (FC) positively correlated with LS (r = 0.81; p < 0.001). FC levels of 100 µg/g and 50 µg/g had a sensitivity of only 40% and 55% to rule out small-bowel CD, with a negative predictive value (NPV) of only 76% and 80%, respectively.

CONCLUSIONS

SBCE contributed to CD diagnosis in a quarter of patients with cPD after a negative standard workup. FC levels correlated with the degree of inflammation defined by the LS. However, the NPV of FC was low, suggesting that SBCE should be considered for patients with cPD even after a negative standard workup.

Deep learning and minimally invasive inflammatory activity assessment: a proof-of-concept study for development and score correlation of a panendoscopy convolutional network

Background

Capsule endoscopy (CE) is a valuable tool for assessing inflammation in patients with Crohn's disease (CD). The current standard for evaluating inflammation are validated scores (and clinical laboratory values) like Lewis score (LS), Capsule Endoscopy Crohn's Disease Activity Index (CECDAI), and ELIAKIM. Recent advances in artificial intelligence (AI) have made it possible to automatically select the most relevant frames in CE.

Objectives

In this proof-of-concept study, our objective was to develop an automated scoring system using CE images to objectively grade inflammation.

Design

Pan-enteric CE videos (PillCam Crohn's) performed in CD patients between 09/2020 and 01/2023 were retrospectively reviewed and LS, CECDAI, and ELIAKIM scores were calculated.

Methods

We developed a convolutional neural network-based automated score consisting of the percentage of positive frames selected by the algorithm (for small bowel and colon separately). We correlated clinical data and the validated scores with the artificial intelligence-generated score (AIS).

Results

A total of 61 patients were included. The median LS was 225 (0-6006), CECDAI was 6 (0-33), ELIAKIM was 4 (0-38), and SB_AIS was 0.5659 (0-29.45). We found a strong correlation between SB_AIS and LS, CECDAI, and ELIAKIM scores (Spearman's r = 0.751, r = 0.707, r = 0.655, p = 0.001). We found a strong correlation between LS and ELIAKIM (r = 0.768, p = 0.001) and a very strong correlation between CECDAI and LS (r = 0.854, p = 0.001) and CECDAI and ELIAKIM scores (r = 0.827, p = 0.001).

Conclusion

Our study showed that the AI-generated score had a strong correlation with validated scores indicating that it could serve as an objective and efficient method for evaluating inflammation in CD patients. As a preliminary study, our findings provide a promising basis for future refining of a CE score that may accurately correlate with prognostic factors and aid in the management and treatment of CD patients.

Pan-Enteric Capsule Endoscopy: Current Applications and Future Perspectives

BACKGROUND

The role of capsule endoscopy in the evaluation of the small bowel is well established, and current guidelines position it as a first-line test in a variety of clinical scenarios. The advent of double-headed capsules further enabled the endoscopic assessment of colonic mucosa and the opportunity for a one-step noninvasive examination of the entire bowel (pan-enteric capsule endoscopy [PCE]).

SUMMARY

We reviewed the technical procedure and preparation of patients for PCE, as well as its current clinical applications and future perspectives. In non-stricturing and non-penetrating Crohn's disease affecting the small bowel and colon, PCE monitors disease activity by assessing mucosal healing, a major treatment outcome, with a higher diagnostic yield than cross-sectional imaging or conventional colonoscopy. Also in ulcerative colitis, double-headed capsules have been used to monitor disease activity noninvasively. Currently, validated scoring systems have been specifically devised for these double-headed capsules and permit a standardized assessment of the inflammatory burden. In suspected mid-lower digestive bleeding, some exploratory studies have demonstrated the feasibility and high diagnostic yield of PCE, which may work as a filter indicating which patients may benefit of further invasive procedures, namely, for planned hemostatic procedures. The possibility of using PCE is also discussed in the context of polyposis syndromes with simultaneous involvement of the small intestine and colon.

KEY MESSAGES

PCE is a feasible, effective, and safe diagnostic procedure to evaluate the small bowel and colon. It has been increasingly explored in the setting of inflammatory bowel diseases and, more recently, in suspected mid-lower digestive bleeding. PCE is expected to reduce the demand for invasive procedures and expand the scope of noninvasive intestinal evaluation in the coming future.

Capsule endoscopy and panendoscopy: A journey to the future of gastrointestinal endoscopy

In 2000, the small bowel capsule revolutionized the management of patients with small bowel disorders. Currently, the technological development achieved by the new models of double-headed endoscopic capsules, as miniaturized devices to evaluate the small bowel and colon [pan-intestinal capsule endoscopy (PCE)], makes this non-invasive procedure a disruptive concept for the management of patients with digestive disorders. This technology is expected to identify which patients will require conventional invasive endoscopic procedures (colonoscopy or balloon-assisted enteroscopy), based on the lesions detected by the capsule, i.e., those with an indication for biopsies or endoscopic treatment. The use of PCE in patients with inflammatory bowel diseases, namely Crohn's disease, as well as in patients with iron deficiency anaemia and/or overt gastrointestinal (GI) bleeding, after a non-diagnostic upper endoscopy (esophagogastroduodenoscopy), enables an effective, safe and comfortable way to identify patients with relevant lesions, who should undergo subsequent invasive endoscopic procedures. The recent development of magnetically controlled capsule endoscopy to evaluate the upper GI tract, is a further step towards the possibility of an entirely non-invasive assessment of all the segments of the digestive tract, from mouth-to-anus, meeting the expectations of the early developers of capsule endoscopy.

Smart Endoscopy Is Greener Endoscopy: Leveraging Artificial Intelligence and Blockchain Technologies to Drive Sustainability in Digestive Health Care

The surge in the implementation of artificial intelligence (AI) in recent years has permeated many aspects of our life, and health care is no exception. Whereas this technology can offer clear benefits, some of the problems associated with its use have also been recognised and brought into question, for example, its environmental impact. In a similar fashion, health care also has a significant environmental impact, and it requires a considerable source of greenhouse gases. Whereas efforts are being made to reduce the footprint of AI tools, here, we were specifically interested in how employing AI tools in gastroenterology departments, and in particular in conjunction with capsule endoscopy, can reduce the carbon footprint associated with digestive health care while offering improvements, particularly in terms of diagnostic accuracy. We address the different ways that leveraging AI applications can reduce the carbon footprint associated with all types of capsule endoscopy examinations. Moreover, we contemplate how the incorporation of other technologies, such as blockchain technology, into digestive health care can help ensure the sustainability of this clinical speciality and by extension, health care in general.

Small Bowel Capsule Endoscopy and Enteroscopy: A Shoulder-to-Shoulder Race

Traditional methods have their limitations when it comes to unraveling the mysteries of the small bowel, an area historically seen as the "black box" of the gastrointestinal tract. This is where capsule endoscopy and enteroscopy have stepped in, offering a remarkable synergy that transcends the sum of their individual capabilities. From their introduction, small bowel capsule endoscopy and device-assisted enteroscopy have consistently evolved and improved, both on their own and interdependently. Each technique's history may be told as a success story, and their interaction has revolutionized the approach to the small bowel. Both have advantages that could be ideally combined into a perfect technique: safe, non-invasive, and capable of examining the entire small bowel, taking biopsies, and applying therapeutical interventions. Until the realization of this perfect tool becomes a reality, the key for an optimal approach lies in the right selection of exploration method. In this article, we embark on a journey through the intertwined development of capsule endoscopy and enteroscopy, exploring the origins, technological advancements, clinical applications, and evolving inquiries that have continually reshaped the landscape of small bowel imaging.

Monitoring of leucine-rich alpha-2-glycoprotein and assessment by small bowel capsule endoscopy are prognostic for Crohn's disease patients

Background and Aim

Endoscopy is important to determine the effectiveness of treatment for Crohn's disease (CD), but searching the entire small intestine is difficult. Thus, we investigated the usefulness of leucine-rich alpha-2 glycoprotein (LRG), a new biomarker for predicting mucosal activity, in evaluating the activity of CD small intestinal lesions. This will further determine whether the results of small bowel capsule endoscopy (SBCE) affect the prognosis of patients with CD.

Methods

A total of 114 patients with CD who underwent SBCE were included. We analyzed the correlation between LRG and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI). The cutoff value of LRG to achieve mucosal healing was calculated using the receiver operating characteristic curve. Then, we compared the presence or absence of intervention and the relapse rate of patients who could not achieve mucosal healing.

Results

The CECDAI correlated with LRG. The calculated LRG value for achieving mucosal healing was ≤11.9. Ninety-one patients were in clinical remission at the time of SBCE. During the follow-up period, 17 patients relapsed. As a result of SBCE, when no treatment intervention was performed in the case of CECDAI ≥3.5, the relapse rate was significantly higher than when CECDAI <3.5 or intervention was performed in the case of CECDAI ≥3.5.

Conclusions

The results reveal that LRG correlates with the activity of the entire small intestine and that SBCE assessment and therapeutic intervention can influence patient prognosis.

Capsule Endoscopy in Inflammatory Bowel Disease: Panenteric Capsule Endoscopy and Application of Artificial Intelligence

Video capsule endoscopy (VCE) of the small-bowel has been proven to accurately diagnose small-bowel inflammation and to predict future clinical flares among patients with Crohn's disease (CD). In 2017, the panenteric capsule (PillCam Crohn's system) was introduced for the first time, enabling a reliable evaluation of the whole small and large intestines. The great advantage of visualization of both parts of the gastrointestinal tract in a feasible and single procedure, holds a significant promise for patients with CD, enabling determination of the disease extent and severity, and potentially optimize disease management. In recent years, applications of machine learning, for VCE have been well studied, demonstrating impressive performance and high accuracy for the detection of various gastrointestinal pathologies, among them inflammatory bowel disease lesions. The use of artificial neural network models has been proven to accurately detect/classify and grade CD lesions, and shorten the VCE reading time, resulting in a less tedious process with a potential to minimize missed diagnosis and better predict clinical outcomes. Nevertheless, prospective, and real-world studies are essential to precisely examine artificial intelligence applications in real-life inflammatory bowel disease practice.

Is Panenteric PillcamTM Crohn's Capsule Endoscopy Ready for Widespread Use? A Narrative Review

Patients diagnosed with Crohn's disease are increasingly subjected to repeat colonoscopic and radiological examinations to assess the extent of the disease severity and the effects of treatment. Pillcam^TM Crohn's video capsule, a modified colon capsule, was developed to generate a minimally invasive mouth to rectum video of the gastrointestinal tract. The capsule provides a wide-angle panoramic mucosal view to assess inflammation, ulceration, stenosis, disease extent, and effect of treatment. This review summarizes the evidence of its utility in both adult and paediatric Crohn's disease and reviews the scoring systems used to quantify findings. The literature survey indicates that the Pillcam^TM Crohn's capsule offers high sensitivity and specificity for the detection of inflammatory lesions and the extent and distribution of disease, and it could be considered a reliable imaging modality in both adults and childhood with Crohn's disease.

Video Capsule Endoscopy Plays an Important Role in the Management of Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory disorder characterized by a transmural inflammation that may involve any part of the gastrointestinal tract. An evaluation of small bowel involvement, allowing recognition of disease extent and severity, is important for disease management. Current guidelines recommend the use of capsule endoscopy (CE) as a first-line diagnosis method for suspected small bowel CD. CE has an essential role in monitoring disease activity in established CD patients, as it can assess response to treatment and identify high-risk patients for disease exacerbation and post-operative relapse. Moreover, several studies have shown that CE is the best tool to assess mucosal healing as part of the treat-to-target strategy in CD patients. The PillCam Crohn's capsule is a novel pan-enteric capsule which enables visualization of the whole gastrointestinal tract. It is useful to monitor pan-enteric disease activity, mucosal healing and accordingly allows for the prediction of relapse and response using a single procedure. In addition, the integration of artificial intelligence algorithms has showed improved accuracy rates for automatic ulcer detection and the ability to shorten reading times. In this review, we summarize the main indications and virtue for using CE for the evaluation of CD, as well as its implementation in clinical practice.

Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021

BACKGROUND

We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD.

METHODS

PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021.

RESULTS

Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD.

CONCLUSIONS

These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

The Effectiveness of a Very Low-Volume Compared to High-Volume Laxative in Colon Capsule Endoscopy

Colon capsule endoscopy (CCE) is a promising modality for colonic investigations, but completion rates (CR) and adequate cleansing rates (ACR) must be improved to meet established standards for optical colonoscopy. Improvements should be made with patient acceptability in mind. We aimed to compare a very low-volume polyethylene glycol (PEG) laxative to a conventional high-volume laxative. We carried out a single-center retrospective comparative cohort study including patients referred for CCE. One hundred and sixty-six patients were included in the final analysis, with eighty-three patients in each group. We found a CR and ACR of 77% and 67% in the high-volume group and 72% and 75% in the very low-volume group, respectively. In the high-volume group, 54% had complete transit and adequate cleansing, whereas this was the case for 63% in the very low-volume group. No statistically significant difference in CR, ACR, or a combination of the two was found. A very low-volume bowel preparation regimen was non-inferior to a high-volume regimen before CCE in terms of CR and ACR.

The diagnostic yield of pan-enteric capsule endoscopy in inflammatory bowel disease: A systematic review and meta-analysis

BACKGROUND AND AIM

Capsule endoscopy (CE) is a non-invasive diagnostic modality enabling real time video imaging of the gastrointestinal (GI) mucosa. Pan-enteric capsule endoscopy (PCE) is now able to thoroughly assess the entire GI tract, including for inflammatory bowel disease (IBD). Our aim was to evaluate the diagnostic accuracy of PCEs in IBD.

METHODS

We comprehensively searched electronic databases (MEDLINE, SCOPUS, EMBASE, and Cochrane Central Register of Controlled Trials) for studies comparing the diagnostic accuracy of PCE with endoscopic evaluation, intestinal ultrasound or magnetic resonance enterography (MRE). Data were analyzed by calculating forest plots and the use of the I² statistic for heterogeneity.

RESULTS

Fourteen studies were identified, with seven studies evaluating PCE diagnostic yield in Crohn's disease (CD) and seven studies in ulcerative colitis (UC). In CD, there was a trend to superiority of PCE over MRE and colonoscopy with a pooled odds ratio (OR) of 1.25 (95% CI, 0.85-1.86%) for the detection of CD. This translates to an increased diagnostic yield of 5% and 7% for PCE compared with MRE and colonoscopy, respectively. PCEs had a diagnostic sensitivity for the detection of UC of 93.8% (95% CI, 87.6-97.0%) and a specificity of 69.8% (95% CI, 38.2-89.6%).

CONCLUSION

PCEs have a comparable diagnostic yield to colonoscopy and MRE in Crohn's disease. The major difficulty remains standardization of PCE scoring systems and the lack of transmural assessment. In UC, PCE has an excellent diagnostic sensitivity and positive predictive value, but there are limitations to its use including the lack of histologic assessment and poor specificity.

Capsule endoscopy in Crohn's disease surveillance: A monocentric, retrospective analysis in Italy

Background

Crohn's disease (CD) is a potentially debilitating condition that burdens Italian healthcare substantially. The symptomatic management relies on prompt therapy adjustment to reduce flares and follow-up diagnostic inputs to maximise remission. Capsule endoscopy (CE) has introduced advantages in CD diagnostics, allowing the direct inspection of the entire gastrointestinal mucosa. The diagnostic procedure is comparable in effort to standard ileocolonoscopy (IC) but requires no anaesthesia. Whether CE follow-up improves clinical outcomes remains to be defined.

Objectives

To provide a preliminary evaluation of CE in terms of clinical outcomes with respect to the standard of care ileocolonoscopy/MRE in Italy.

Methods

This retrospective analysis utilises anonymised, monocentric data from the S. Orsola-Malpighi Hospital IBD database in Bologna, Italy, collected between 1999 and 2019. Out of 421 adult patient records, 100 were included in the analysis (50 per arm, matched per demographic and clinical characteristics). The CE represented the intervention arm, whereas ileocolonoscopy/magnetic resonance enterography was the standard of care. The use of biologics, symptomatology course, and surgery were the outcomes.

Results

The two techniques performed similarly overall. In general, no significant difference emerged in the use of biologics. The use of biologics appears reduced in the CE group, only in L4 patients after the first follow-up year. Similarly, surgery was seemingly less frequent among L4 patients in the CE group. No difference was found between groups in flare occurrence and duration. CE patients might have experienced longer and earlier first remissions, but no long-term difference persisted.

Conclusions

The CE group showed an apparent reduction in biologics and surgery, limiting to L4 diagnoses. More extensive, prospective, multicentre, randomised studies must corroborate these preliminary findings.

Key research questions for implementation of artificial intelligence in capsule endoscopy

BACKGROUND

Artificial intelligence (AI) is rapidly infiltrating multiple areas in medicine, with gastrointestinal endoscopy paving the way in both research and clinical applications. Multiple challenges associated with the incorporation of AI in endoscopy are being addressed in recent consensus documents.

OBJECTIVES

In the current paper, we aimed to map future challenges and areas of research for the incorporation of AI in capsule endoscopy (CE) practice.

DESIGN

Modified three-round Delphi consensus online survey.

METHODS

The study design was based on a modified three-round Delphi consensus online survey distributed to a group of CE and AI experts. Round one aimed to map out key research statements and challenges for the implementation of AI in CE. All queries addressing the same questions were merged into a single issue. The second round aimed to rank all generated questions during round one and to identify the top-ranked statements with the highest total score. Finally, the third round aimed to redistribute and rescore the top-ranked statements.

RESULTS

Twenty-one (16 gastroenterologists and 5 data scientists) experts participated in the survey. In the first round, 48 statements divided into seven themes were generated. After scoring all statements and rescoring the top 12, the question of AI use for identification and grading of small bowel pathologies was scored the highest (mean score 9.15), correlation of AI and human expert reading-second (9.05), and real-life feasibility-third (9.0).

CONCLUSION

In summary, our current study points out a roadmap for future challenges and research areas on our way to fully incorporating AI in CE reading.

Small bowel Crohn's disease: optimal modality for diagnosis and monitoring

PURPOSE OF REVIEW

This paper reviews different imaging options for small bowel (SB) Crohn's disease (CD) patients.

RECENT FINDINGS

In total, 80% of patients suffering from CD have SB involvement, being the exclusive manifestation in 30% of cases. As the proximal disease is related to poor response to treatment, a higher rate of stenosis and a greater need for surgical treatment, a SB assessment should be performed. This evaluation should be done not only once the disease has been diagnosed but periodically. The former to determine the extent of the disease, and the latter according to a treat-to-target strategy. Available techniques such as magnetic resonance imaging, intestinal ultrasound and capsule endoscopy (CE) have shown good accuracy parameters in CD patients. Cross-sectional studies are superior for penetrating and stricturing disease, whereas CE is excellent for proximal involvement and mucosal healing. Local expertise and availability may lead the election between techniques, nevertheless, they should not be considered as competitors but as complementary tools.

SUMMARY

SB involvement in CD patients is frequent and related to poorer outcomes. Hence, SB evaluation should be screened after diagnosis and routinely during the follow-up.

Video capsule endoscopy in inflammatory bowel disease

Since its introduction into clinical practice in 2000, capsule endoscopy (CE) has become an important procedure for many pathologies of small bowel (SB) diseases, including inflammatory bowel disease (IBD). Currently, the most commonly used capsule procedures are small bowel capsule endoscopy (SBCE), colon CE (CCE), and the recently developed pan-enteric CE that evaluates the SB and colon in patients with Crohn's disease (CD). SBCE has a higher diagnostic performance compared to other radiological and conventional endoscopic modalities in patients with suspected CD. Additionally, CE plays an important role in monitoring the activity of CD in SB. It can also be used in evaluating response to anti-inflammatory treatment and detecting recurrence in postsurgical patients with CD who underwent bowel resection. Due to its increasing use, different scoring systems have been developed specifically for IBD. The main target with CCE is ulcerative colitis (UC). The second-generation colon capsule has shown high performance for the assessment of inflammation in patients with UC. CCE allows noninvasive evaluation of mucosal inflammation with a reduced volume of preparation for patients with UC.

Review: Colon Capsule Endoscopy in Inflammatory Bowel Disease

The COVID-19 pandemic has caused considerable disruption in healthcare services and has had a substantial impact on the care of patients with chronic diseases, such as inflammatory bowel disease. Endoscopy services were significantly restricted, resulting in long waiting lists. There has been a growing interest in the use of capsule endoscopy in the diagnostic pathway and management of these patients. This review explores the published literature on the role of colon capsule endoscopy in ulcerative colitis and Crohn’s disease as a method for mucosal assessment of extent, severity, and response to treatment. Colon capsule preparation regimens and scoring systems are reported. The studies indicate that, despite inherent limitations of minimally invasive capsule endoscopy, there is increasing evidence to support the use of the second-generation colon capsule in inflammatory bowel disease evaluation, providing an additional pathway to expedite investigation of appropriate patients especially during and after the pandemic.

Does capsule endoscopy impact clinical management in established Crohn's disease?

BACKGROUND

Capsule endoscopy (SBCE) has developed a relevant role in patients with established Crohn's Disease (CD). However, evaluation of the impact in clinical management has been scarce.

AIMS

To evaluate therapeutic impact of SBCE in an 11-year real-life cohort of known CD patients.

METHODS

Retrospective single center study including all patients with established CD submitted to SBCE procedure from 01/01/2008 to 31/12/2019. Patency capsule was used in selected patients. Small bowel mucosal inflammation was quantified using Lewis score. Therapeutic impact was defined as a change in CD-related treatment recommended based on SBCE results. Patients were assigned to four groups regarding SBCE indication: staging, flare, post-op and remission.

RESULTS

From the 432 SBCE performed 87.5% were conclusive. Active disease was present in 63.7 of patients; 41.6% mild inflammation and 21.9% moderate-to-severe activity. A change of management was guided by SBCE in 51.3% of procedures: 199 (46.1%) escalation and 23 (5.3%) de-escalation, with significant changes in all groups. Escalation increased with disease activity: 57.8% in mild and 89.5% in moderate-to-severe disease. De-escalation was conducted in 13.9% procedures with mucosal healing and 1.1% with mild disease.

CONCLUSION

SBCE is a useful tool for guiding therapeutic management in CD patients both for treatment escalation and de-escalation.

Panintestinal capsule endoscopy in patients with celiac disease

INTRODUCTION

Capsule endoscopy has proven its utility in diagnosing villous atrophy and lymphoma in patients with celiac disease. Recently, a novel capsule endoscopy system was introduced which enables the examination of the small and large bowel. So far, it has not been evaluated in patients with celiac disease.

OBJECTIVE

The primary objective of this study was to evaluate the novel panintestinal capsule endoscopy system in patients with celiac disease.

METHODS

Eleven patients with histologically proven celiac disease (Marsh 0-IV), who underwent a panintestinal capsule endoscopy between March 2018 and April 2019 at our institution, were included in this retrospective single-center study. All patients performed standard bowel preparation prior to the examination. Diagnostic yield, safety and therapeutic impact were analyzed. In addition, the correlation between capsule endoscopy findings and the histology of the duodenal mucosa was assessed.

RESULTS

Panintestinal capsule endoscopy was feasible and produced an acceptable visualization quality in all cases. Concordance of capsule endoscopy findings with the Marsh classification showed a good correlation (r = 0.8). No lymphomas were detected. Evaluation of the colon revealed diminutive polyps (median size 4 mm) in 18% of patients.

CONCLUSIONS

The novel panintestinal capsule endoscopy system shows a fair correlation with the Marsh classification in patients with celiac disease. It is also capable of identifying colon polyps. Therefore, the novel panintestinal capsule endoscopy system can be considered for patients with celiac disease and an indication for capsule endoscopy.

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.

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.

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.

Clinical feasibility of panintestinal (or panenteric) capsule endoscopy: a systematic review

In recent years, panintestinal capsule endoscopy (PCE) with double-headed capsules has been used to perform complete, single-sitting exploration of both small bowel and colon in different clinical conditions. Double-headed capsules for colonic examination (CCE) have been exploited first in this setting, followed by newer generations of capsules (i.e. PillCam Crohn, PCC) specifically engineered for this purpose. The aim of this study was to evaluate the feasibility of PCE in the form of a systematic review. We performed a comprehensive literature search to identify papers in which CE was specifically used for a PCE of the gastrointestinal tract. Data on CE, bowel preparation regimen, rate of cleanliness and completeness, and data on transit times were analyzed. The primary outcome was to assess the feasibility of a whole-gut exploration with CE. Sixteen (n = 16) studies including 915 CE procedures with CCE1 (n = 134), CCE2 (n = 357) and PCC (n = 424) were included. 13/16 studies were performed in the setting of Crohn's disease. Cleanliness and completeness rates were acceptable in all studies, ranging from 63.9% and 68.6% to 100%, respectively. In conclusion, PCE is a feasible technique, although further structured studies are needed to explore its full potential.

The utility of faecal and urine biomarkers for small bowel diseases

PURPOSE OF REVIEW

Small bowel diseases pose a unique diagnostic and management challenge and often requires tertiary specialist referral. The use of biomarkers may provide a cheap, noninvasive tool to assess the small bowel in terms of diagnosis, offering a better way to triage referrals and select patients for early management. This review looks at the most recent evidence behind the use of several faecal and urine biomarkers for small bowel diseases.

RECENT FINDINGS

Faecal calprotectin shows the most promise, with evidence to support its role in predicting relapse postsurgery and monitoring treatment response in patients with Crohn's disease. A faecal calprotectin less than 50 μg/g may also be used as a cut-off to triage further investigation. Faecal lactoferrin also appears promising as a marker of small bowel inflammation. A positive faecal immunohistochemistry test precapsule may help to prioritize referrals for obscure bleeding.

SUMMARY

The use of biomarkers in the diagnosis and management of small bowel disease is still controversial and remains unclear. More studies are required to further develop their potential and before societal guidelines can be developed to direct their appropriate use in clinical practice.

Capsule endoscopy - Recent developments and future directions

INTRODUCTION

Capsule endoscopy (CE) is an established modality in the diagnostic algorithm of small bowel (SB) pathology. Its use has expanded for investigation of upper and lower gastrointestinal diseases with similar prototypes.

AREAS COVERED

This review covers the role and recent advances of CE, as a non-invasive investigative tool.

EXPERT OPINION

The use of upper gastrointestinal CE is useful in patients who require surveillance for varices particularly in the current era of the COVID-19 pandemic. It has also shown high accuracy in the detection of upper gastrointestinal hemorrhage in patients presenting with a suspicion of hemorrhage. Findings on CE help to guide further management by device-assisted enteroscopy. The data on colon CE suggest comparable diagnostic accuracy to colonoscopy for polyp detection; however, more evidence is required in the high-risk group. Crohn's CE has become an integral part of the management of patients with Crohn's disease offering a comparative assessment tool post escalation of therapy. Artificial intelligence within CE has demonstrated similar if not better diagnostic yield compared to the human with a significantly shorter reading time. Artificial intelligence is likely to be in-built within CE reading platforms over the next few years minimizing reporting time and human error.