The role of small bowel endoscopy in small bowel Crohn's disease: when and how?

Leucine-rich alpha-2 glycoprotein as a superior biomarker to C-reactive protein for detecting small bowel lesions in Crohn's disease

BACKGROUND

Achievement of endoscopic healing (EH) is significant in the clinical practice of inflammatory bowel disease as it is correlated with improved prognosis. Existing biomarkers, including C-reactive protein (CRP), have relatively low accuracy for predicting EH, especially in small intestinal lesions in Crohn's disease (CD); thus, noninvasive and more accurate biomarkers are required. Leucine-rich alpha-2 glycoprotein (LRG), a 50-kD protein, is produced under inflammatory conditions and has been reported to be useful in assessing disease activity in inflammatory bowel disease. However, the usefulness of LRG in small intestinal lesions in CD remains inconclusive.

AIM

To determine the usefulness of LRG for EH in small bowel lesions in CD and compare it with CRP.

METHODS

This study included 133 consecutive patients with CD who underwent balloon-assisted enteroscopy between June 2021 and March 2024 at Shiga University of Medical Science Hospital (Otsu, Japan). We retrospectively analyzed endoscopic scores in each of the ileum and colon and four markers including LRG, CRP, albumin, and Harvey-Bradshaw index (HBI). Spearman's rank correlation coefficient and receiver operating characteristic analysis were performed.

RESULTS

Either active ileal or colonic lesions exhibited significant differences in LRG, CRP, albumin, and HBI compared with EH. CRP, albumin, and HBI showed a worse correlation with endoscopic activity in the ileum than that in the colon; however, LRG did not show a worse correlation (colon, r = 0.5218; ileum, r = 0.5602). Receiver operating characteristic analysis revealed that LRG for EH in the ileum and colon had the same cutoff values of 12.4 μg/mL. Comparing the areas under the curve of LRG and CRP for predicting EH in the ileum revealed a significantly higher areas under the curve of LRG (95% confidence interval, 0.017-0.194; P = 0.024), whereas the two showed no significant difference in the colon.

CONCLUSION

LRG is a useful biomarker in assessing the endoscopic activity of CD and is more useful than CRP in the small intestine.

Utility of panenteric capsule endoscopy for the detection of small-bowel Crohn's disease in patients with a normal magnetic resonance enterography: A prospective observational pilot study

BACKGROUND AND AIM

Capsule endoscopy allows the direct visualization of the small bowel. We examined the diagnostic utility of a new modality, namely panenteric Crohn's capsule endoscopy (CE), in detecting active small-bowel Crohn's disease (CD) in those with normal magnetic resonance enterography (MRE).

METHODS

We prospectively recruited patients with a diagnosis of CD or suspected small-bowel CD in whom the MRE was normal. Inclusion criteria included abdominal symptoms and abnormal serum or fecal biomarkers. The primary outcome was the detection of active small-bowel CD (measured through the Lewis score [LS]). Secondary outcomes included change in Montreal classification for those with a pre-existing CD diagnosis, change in medical therapy, clinical activity, and biomarkers at baseline and 6 months, and quality-of-life measures.

RESULTS

A total of 22 patients with a diagnosis of CD or suspected new diagnosis were recruited, with CE complete to the caecum in 21 and 18/21 (86%) showing evidence of active small-bowel CD (LS > 135). Of the patients with a pre-existing diagnosis of CD, 9/11 (82%) had a change in Montreal classification. At 6 months following CE, 17/18 (94%) had clinician-directed change in therapy. This correlated with an improvement in the quality of life (P < 0.05 as per the Short Inflammatory Bowel Disease Questionnaire), a reduction in the Harvey Bradshaw index (median: 7-4, P < 0.001), and favorable CRP and albumin response.

CONCLUSION

Crohn's CE is a useful diagnostic test for assessing active small-bowel CD when imaging is normal but clinical suspicion is high. Crohn's CE should be integrated into the diagnostic algorithm for small-bowel CD.

Aptamer-Functionalized Microbubbles Targeted to P-selectin for Ultrasound Molecular Imaging of Murine Bowel Inflammation

PURPOSE

Our objectives were to develop a targeted microbubble with an anti-P-selectin aptamer and assess its ability to detect bowel inflammation in two murine models of acute colitis.

PROCEDURES

Lipid-shelled microbubbles were prepared using mechanical agitation. A rapid copper-free click chemistry approach (azide-DBCO) was used to conjugate the fluorescent anti-P-selectin aptamer (Fluor-P-Ap) to the microbubble surface. Bowel inflammation was chemically induced using 2,4,6-trinitrobenzenesulfonic acid (TNBS) in both Balb/C and interleukin-10-deficient (IL-10 KO) mice. Mouse bowels were imaged using non-linear contrast mode following an i.v. bolus of 1 × 10⁸ microbubbles. Each mouse received a bolus of aptamer-functionalized and non-targeted microbubbles. Mouse phenotypes and the presence of P-selectin were validated using histology and immunostaining, respectively.

RESULTS

Microbubble labelling of Fluor-P-Ap was complete after 20 min at 37 ̊C. We estimate approximately 300,000 Fluor-P-Ap per microbubble and confirmed fluorescence using confocal microscopy. There was a significant increase in ultrasound molecular imaging signal from both Balb/C (p = 0.003) and IL-10 KO (p = 0.02) mice with inflamed bowels using aptamer-functionalized microbubbles in comparison to non-targeted microbubbles. There was no signal in healthy mice (p = 0.4051) using either microbubble.

CONCLUSIONS

We constructed an aptamer-functionalized microbubble specific for P-selectin using a clinically relevant azide-DBCO click reaction, which could detect bowel inflammation in vivo. Aptamers have potential as a next generation targeting agent for developing cost-efficient and clinically translatable targeted microbubbles.

Enteroscopy in Crohn's Disease: Are There Any Changes in Role or Outcomes Over Time? A KASID Multicenter Study

Background/Aims

Although balloon-assisted enteroscopy (BAE) enables endoscopic visualization of small bowel (SB) involvement in Crohn's disease (CD), there is no data on the changes in outcomes over time. We therefore investigated the changes in BAE use on CD patients over different time periods in terms of its role and clinical outcomes.

Methods

We used a multicenter enteroscopy database to identify CD patients with SB involvement who underwent BAE (131 procedures, 116 patients). We compared BAE-related factors and outcomes between the first period (70 procedures, 60 patients) and the second period (61 procedures, 56 patients). The specific cutoff point for dividing the two periods was 2007, when BAE guidelines were introduced.

Results

Initial diagnosis of SB involvement in CD was the most common indication for BAE during each period (50.0% vs 31.1%, p=0.034). The largest change was in the number of BAE uses for stricture evaluation and/or treatment, which increased significantly in the latter period (2.9% vs 21.3%, p=0.002). The diagnostic yield in patients with suspected CD was 90.7% in the first period and 95.0% in the second (p=0.695). More endoscopic interventions were performed in the second period than in the first (5.1% vs 17.6%, p=0.041). Enteroscopic success rates were high throughout (100% in the first period vs 80.0% in the second period, p>0.999). In the first and second periods, therapeutic plans were adjusted in 62.7% and 61.4% of patients, respectively.

Conclusions

The overall clinical indications, outcomes, and effectiveness of BAE were constant over time in CD patients with SB involvement, with the exception that the frequency of enteroscopic intervention increased remarkably.

Small Bowel Enteroscopy - A Joint Clinical Guideline from the Spanish and Portuguese Small Bowel Study Groups

The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication and on its diagnostic and therapeutic yields. A set of recommendations were issued accordingly.

Small Bowel Adenocarcinoma, Version 1.2020, NCCN Clinical Practice Guidelines in Oncology

Small bowel adenocarcinoma (SBA) is a rare malignancy of the gastrointestinal tract that has increased in incidence across recent years. Often diagnosed at an advanced stage, outcomes for SBA are worse on average than for other related malignancies, including colorectal cancer. Due to the rarity of this disease, few studies have been done to direct optimal treatment, although recent data have shown that SBA responds to treatment differently than colorectal cancer, necessitating a separate approach to treatment. The NCCN Guidelines for Small Bowel Adenocarcinoma were created to establish an evidence-based standard of care for patients with SBA. These guidelines provide recommendations on the workup of suspected SBA, primary treatment options, adjuvant treatment, surveillance, and systemic therapy for metastatic disease. Additionally, principles of imaging and endoscopy, pathologic review, surgery, radiation therapy, and survivorship are described.

Gastroduodenal lesions detected during small bowel capsule endoscopy: incidence, diagnostic and therapeutic impact

BACKGROUND

Capsule endoscopy was primarily designed for the investigation of the small bowel. However, it may also identify lesions in other segments of the gastrointestinal tract. The aim of the current study was to evaluate the incidence of gastroduodenal abnormalities during small bowel capsule endoscopy and its impact on patient diagnosis and management.

PATIENTS AND METHODS

This study is a retrospective analysis of data from 2,217 consecutive capsule endoscopy procedures performed at a single tertiary-care center between January 2008 and February 2016. Patient baseline characteristics, gastroduodenal lesions, diagnosis and management before and after capsule endoscopy were recorded and a descriptive analysis was performed.

RESULTS

Two thousands and two hundred seventeen patients were finally included in the analysis. One thousand and seventy patients were male (48.2%) and the mean age was 56.1 ± 19.5 years (range: 12-93). Obscure gastrointestinal bleeding (52.3%) and inflammatory bowel disease (18.3%) were the main procedure indications. Gastroduodenal abnormalities were detected by capsule endoscopy in 696 (31.4%) of 2,217 patients. The most common types of missed gastric and duodenal lesions found were gastric erosions (35.4%), findings suggestive of chronic gastritis (22.9%), duodenal erosions (28.1%) and duodenal erythema (23.5%). This information had a clinical or diagnostic impact of 26.2% and a therapeutic impact of 15.5%.

CONCLUSION

Capsule endoscopy detects not only small bowel lesions but also some gastroduodenal lesions that may be overlooked during an initial gastroscopy. Therefore, all gastroduodenal images should be read during small bowel capsule endoscopy as it may provide relevant information that result in changes in patient management.

Capsule Endoscopy Validation of the Magnetic Enterography Global Score in Patients with Established Crohn's Disease

BACKGROUND AND AIMS

Capsule endoscopy [CE] and magnetic resonance enterography [MRE] are prime modalities for evaluation of the small bowel in Crohn's disease [CD]. Detection of proximal small bowel [SB] inflammation in CD by MRE is challenging. Currently available quantitative MRE scores do not incorporate proximal SB data. The MRE global score [MEGS] was designed for quantitative evaluation of the entire digestive tract; its accuracy in the proximal SB has not previously been evaluated. This study compared the evaluation of the small bowel inflammation by MEGS and CE-derived quantitative score (the Lewis score[LS]).

METHODS

CD patients in stable clinical remission were prospectively recruited and underwent MRE and CE; faecal calprotectin [FC] levels were obtained. MEGS was calculated for each SB segment and the entire SB [SBMEGS]. SB inflammation on CE was quantified using LS. A cumulative Lewis score [C-LS] was calculated based on summation of three tertiles scores.

RESULTS

Fifty patients were included. There was a significant correlation of SBMEGS with LS and C-LS [r = 0.61 and 0.71, both p = 0.001]. The correlation with FC was stronger for MEGS than for LS or C-LS [r = 0.68 vs r = 0.46 vs r = 0.53, all p = 0.001]. The correlation between the proximal LS and MEGS was significant [r = 0.55, p = 0.001]; median MEGS was significantly different in patients, with LS values consistent with mucosal healing, mild and moderate-to-severe inflammation.

CONCLUSIONS

MEGS provides accurate evaluation of the SB and strongly correlates with FC; the main advantage of MEGS is the accurate quantification of proximal SB inflammation unavailable for alternative MRE scores.

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

Background/Aims

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

Methods

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

Results

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

Conclusions

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

An update on small bowel endoscopy

PURPOSE OF REVIEW

The breakthrough success of capsule endoscopy and device-assisted enteroscopy has inspired researchers to test and push the boundary of these technologies. The authors herein summarize the latest and most significant studies with clinical impact.

RECENT FINDINGS

Competing capsule endoscopy models have enriched the platform of this wireless device. The role of capsule endoscopy in Crohn's disease is expanding as we learn more of the significance of disease distribution and response to treatment. The benefit of capsule endoscopy in abdominal pain has previously been sceptical, but may have a role. Device-assisted enteroscopy demonstrates significant benefit in the management of patients with Crohn's disease and Peutz-Jeghers syndrome. On the contrary, long-term data suggest that endotherapy to small bowel angioectasia may not be as beneficial to patients as we once thought. The role of device-assisted enteroscopy in novel territory, including coeliac disease and endoscopic retrograde cholangiopancreatography, continues to be tested.

SUMMARY

The limit of capsule endoscopy and enteroscopy is yet to be reached. Accumulating long-term data alludes to the benefits of our current practice while spawning novel indications for small bowel endoscopy.

Quality Indicators for Small Bowel Capsule Endoscopy

Capsule endoscopy (CE) enables evaluation of the entire mucosal surface of the small bowel (SB), which is one of the most important steps for evaluating obscure gastrointestinal bleeding. Although the diagnostic yield of SB CE depends on many clinical factors, there are no reports on quality indicators. Thus, the Korean Gut Image Study Group (KGISG) publishes an article titled, “Quality Indicators for Small Bowel Capsule Endoscopy” under approval from the Korean Society of Gastrointestinal Endoscopy (KSGE). Herein, we initially identified process quality indicators, while the structural and outcome indicators are reserved until sufficient clinical data are accumulated. We believe that outcomes of SB CE can be improved by trying to meet our proposed quality indicators.

Clinical outcome after enteroscopy for small bowel angioectasia bleeding: A Korean Associateion for the Study of Intestinal Disease (KASID) multiceter study

BACKGROUND AND AIMS

Angioectasias are the most common sources of bleeding in the small bowel. They can be treated using balloon-assisted enteroscopy (BAE). This study aimed to identify the rebleeding rate and associated factors after BAE in patients with small bowel angioectasia bleeding.

METHODS

We retrospectively analyzed the records of patients with bleeding due to small bowel vascular lesion in a multicenter enteroscopy database including 1108 BAEs. Finally, in rebleeding analysis, we analyzed 66 patients with angioectasia on the basis of the Yano-Yamamoto classification. Patients who had undergone endotherapy (ET) were divided into ET (n = 45) and non-ET (n = 21) groups. Rebleeding was defined as evidence of bleeding at least 30 days after BAE.

RESULTS

Fifty-three patients (80.4%) underwent only one-side enteroscopy. The most common ET was argon plasma coagulation (87.2%). During a mean follow-up duration of 24.5 months, ET and non-ET groups had rebleeding rates of 15.6% and 38.1% (P = 0.059), respectively. Median rebleeding time of ET and non-ET groups was 32.5 and 62 months, respectively. Liver cirrhosis (LC), low platelet count (< 10⁵ /μL), and transfusions were the rebleeding-associated factors in the univariate analysis. In the multivariate analysis, the presence of LC (HR 4.064, 95% CI 1.098-15.045; P = 0.036) was the only independent rebleeding-associated risk factor.

CONCLUSIONS

ET using BAE did not significantly affect the rebleeding rate in patients with small bowel angioectasia bleeding. An independent rebleeding risk factor was the presence of LC. Regardless of ET, careful long-term follow-up may be needed, especially in LC patients with small bowel angioectasia bleeding.