Introduction

Double balloon enteroscopy(DBE) and Magnetic resonance enterography (MRE) are routine examination to detect lesions in the small intestine of Crohn’s disease(CD). However, twice bowel preparation within several days reduces patients’ satisfaction and compliance.

Aims & Methods

This study combined these two examinations on the same day with only one bowel preparation was required and compared the quality of DBE and MREC with two bowel preparations. This is a retrospective study collected 243 CD patients received both DBE and MREC within three days between April 2023 and April 2024. Patients in OBP group took bowel cleansing medication the night before two examinations. They underwent MREC and DBE in the order the next day: received MRMC in the morning and had DBE in the afternoon. Patients in TBP group underwent twice bowel preparations, MRMC and DBE as scheduled time within three days. Overall sex- and age-adjust analysis was performed.

Results

A total of 123 patients was in one bowel preparation (OBP) group and 120 in twice bowel preparation (TBP) group. 115(95.83%) patients qualified for bowel preparation at both examinations, 1(0.83%) only qualified for bowel preparation at MREC, and 4(3.33%) only qualified for bowel preparation at DBE in OBP group. While in TBP group, 116(94.31%) patients had bowel preparations qualified in both examinations, 2(1.63%) patients had bowel preparations only qualified in MRE, and 5(4.06%) patients had bowel preparations only qualified in DBE(P=0.81).
The average depth of insertion was 255.00±70.52 cm in OBP and 255.59±95.83 cm in TBP for the anterograde approach from the pylorus (P=0.98) and 144.70±75.40cm vs. 155.06±98.35cm for the retrograde procedures beyond the ileocecal valve (P=0.41). Complications of hypoglycemia was observed in 7(5.83%) patients in OBP group and 17(13.82%) patients in TBP group(P=0.037). The questionnaire results showed that 82.50% (99/120) of patients in OBP group while 68.29% (84/123) of patients in TBP group were satisfied with the process of examination(P=0.01). The mean intervention depth of OBP and TBP was 255.00±70.52 cm and 255.59±95.83 cm（P=0.98），and the mean intervention depth of OBP and TBP was 144.70± 75.40 cm and 155.06± 98.35 cm（P=0.41）. In this paper，we discuss the relationship between the mechanism and the relationship between the mechanism. The results showed that the patients were satisfied with the inspection process of OBP group and the patients were satisfied with the inspection process of OBP group，and the patients were satisfied with the inspection process of TBP group.

Conclusion

One bowel preparation for DBE and MRE has similar effect as split-dose bowel preparation, and increases the compliance and tolerance of patients.

Disclosure

None

Introduction

Crohn’s disease (CD) may manifest as perianal disease (PD) in up to 36% of cases. In the majority, PD occurs simultaneously or after the diagnosis of small bowel CD. Diagnosing CD in patients with isolated PD can be challenging. Small bowel capsule endoscopy (SBCE) has been shown to have a higher diagnostic yield for small bowel findings compatible with CD than other modalities.

Aims & Methods

This study aimed to assess the impact of SBCE as a diagnostic tool for CD in patients with isolated PD.
Retrospective cohort study spanning 2008 to 2023. Adult patients with isolated PD (recurrent fissures, trans-/supra-/extra-sphincteric fistula or abscess) and negative conventional workup for CD (ileocolonoscopy and cross-sectional imaging) who underwent SBCE (Pillcam, Given®) were included. Patients using nonsteroidal anti-inflammatory drugs or with a CD history were excluded. Demographics, biomarkers, SBCE findings and subsequent management were recorded and analyzed.

Results

Forty patients (mean age 40.2 years, 67.5% females) were included. SBCE identified findings compatible with small bowel CD (aphthous ulcerations, linear/circumferential ulcers and stenosis) in 32.5% (13 patients), enabling diagnosis and subsequent treatment in all of them, based on disease severity. In this group, mean previous fecal calprotectin (FC) was 722.2µg/g, but FC was inferior to 200µg/g in 46.2% (6 patients). In 4 patients (10%) with negative SBCE, isolated perianal CD was assumed and immunosuppressors were started. There was no statistically difference in FC of the patients with positive and negative SBCE. Laboratory findings (C-reactive protein, albumin), tobacco use and family history of CD/ulcerative colitis did not show significant associations with SBCE findings.

Conclusion

For patients with PD and a negative conventional CD workup, SBCE demonstrated a 32.5% incremental diagnostic yield, leading to therapy initiation based on severity.

Introduction

Recent studies implicate visceral adiposity in various bad outcomes of Inflammatory Bowel Disease. Patients with moderate to severe Crohn’s Disease involving the small bowel are especially difficult to treat. The study aimed to seek any correlation between visceral fat and response to biologic therapy in this group of patients with the use of computed tomography enterography (CTE).

Aims & Methods

This was a retrospective cohort of patients with Crohn’s Disease of the small bowel who underwent baseline assessment with CTE before the start of a new biologic therapy. Repeat imaging assessment with CTE was performed 6 to 12 months post new treatment initiation. Examinations were performed in a 16-sclice CT scanner. A single cross sectional CT slice at the L3 level was used for the segmentation of visceral and subcutaneous adipose tissue with syngo via dedicated software. We measured the ratio of visceral to subcutaneous adipose tissue (VAT/SAT). The primary outcome was radiologic response: disease worsening vs complete response, partial response or stable disease. Secondary outcomes were clinical response, treatment persistence, Crohn’s related surgeries and hospitalizations.

Results

A total of 114 exams from 62 patients were included in the study. Baseline disease characteristics were: median age 40 years (23-76), median disease duration 15 years (1-40), median BMI 24 (18-46), median body weight 71 Kg (45-160), stricturing disease 72%, previous surgery 56%, smokers 30%. Most patients received anti-TNF agents: infliximab 40%, adalimumab 40%, ustekinumab 15%, vedolizumab 5%. Visceral fat > 12 was recorded in 65.8% of patients. VAT/SAT was associated with radiologic response (p=0,03), clinical response (p=0,02) and treatment persistence (p=0,03), but not with surgeries or hospitalizations. Multivariate analysis confirmed the statistical correlation of VAT/SAT with radiologic response. Interestingly enough, no specific type of biologic therapy or disease characteristic showed any association with the primary outcome. Baseline BMI, weight and visceral fat volume also failed to correlate with response to therapy.

Conclusion

The use of visceral to subcutaneous adipose tissue ratio to quantify visceral adiposity helped to predict response to biologic therapy in Crohn’s Disease patients with disease of the small bowel. This might confer an added value of enterography to other imaging modalities as for example intestinal ultrasound. Visceral fat seems to play an important role in inflammatory bowel disease and its accurate assessment may aid to risk stratify patients and plan therapy accordingly.

Introduction

The correlation between fecal calprotectin (FC) levels and small bowel (SB) inflammation in patients with Crohn's Disease (CD) remains a subject of debate.

Aims & Methods

This study aims to investigate the relationship between FC levels and SB inflammatory activity in patients diagnosed with SB CD.
We conducted a retrospective cohort study involving patients with SB CD who underwent small bowel capsule endoscopy (SBCE) and FC testing. Patients with colon inflammation were excluded. Participants were categorized into four groups based on their SB inflammatory status: no inflammation (all three SB tertiles showed Lewis Score (LS) <135); proximal SB inflammation (first and/or second SB tertiles had LS ≥ 135, with no inflammation in the third SB tertile); distal SB inflammation (third SB tertile had LS ≥ 135, with no inflammation in the proximal SB); pan-SB inflammation (both proximal and distal SB with inflammation).

Results

A total of 87 patients were included in the study, with a median age of 35 years, 75.9% being female. The distribution of inflammation among the patients was as follows: no inflammation in 21.8%; proximal inflammation in 4.6%; distal inflammation in 33.3%; pan-SB inflammation in 40.4%.
FC median values exhibited an ascending trend along the SB axis: no inflammation 58 µg/g (33-180); proximal SB inflammation 65 µg/g (30-128); distal SB inflammation 122 µg/g (42-507); pan-SB inflammation 400 µg/g (205-852).
Statistically significant differences in FC levels were observed between pan-SB inflammation vs. isolated proximal inflammation (p = 0.014), and isolated distal inflammation (p = 0.012).
Additionally, FC showed a positive correlation with LS in the second (r = 0.464, p<0.001) and third tertiles (r = 0.435, p<0.001), but no correlation was noted in the first tertile.
FC demonstrated good predictive capacity for identifying inflammation in the distal SB and pan-SB vs. no inflammation and proximal inflammation, with an area under the curve of 0.790 (p < 0.001) and an optimal cutoff value of 228 µg/g.

Conclusion

FC levels correlate positively with the presence of SB lesions in the second and third tertiles of the small bowel. However, it is not a reliable marker for detecting inflammation in the first tertile, highlighting the importance of conducting a SBCE in these patients.

Introduction

Small bowel capsule endoscopy (SBCE) is a recommended modality to investigate suspected small bowel Crohn’s disease (CD). The Interational Conference on Capsule Endoscopy (ICCE) set forward criteria to optimize patient selection and diagnostic yield. Capsule candidates should meet one criterion from group A (GI symptoms) along with 1 other criterion from group B/C/D (extraintestinal symptoms/ inflammatory markers /abnormal radiology).

Aims & Methods

The aim of this study is to evaluate the diagnostic performance when ICCE criteria are satisfied in those referred for SBCE with suspected CD. We performed a retrospective single-center study of patients referred for SBCE with suspected CD between March 2021 and March 2024. Demographics, clinical and capsule data were assessed from our hospital’s database and recorded. Patients with incomplete data were excluded. A positive SBCE was defined as a Lewis Score (LS) ≥135. Patients were grouped according to ICCE criteria: ICCE+ were those who satisfied ≥ 2 ICCE criteria and ICCE- were those who did not fulfil criteria. Where available, histopathological results, MDT outcomes and treatment decisions were analyzed to determine CD diagnosis.

Results

A total of 335 of 433 capsules for suspected Crohn’s disease were included (58.5% female, mean age 42 years). In all, 82 capsules (24.5%) had clinically significant enteritis (median LS= 266, range 135-6600). 119 patients (35.5%) satisfied ICCE criteria; ICCE A+B (n=3, 2%), ICCE A+C (n=82, 69%), ICCE A+D (n=19,16%), ICCE x3 (n=15, 13%). Of those, 48 patients (40%) had a positive capsule (average LS = 917.46). As expected ICCE + cases were statistically more likely to have significant enteritis compared with ICCE – cases; 48/119 (40%) versus 34/216 (16%) respectively, OR 3.49, p< 0.0001, 95%CI 2.0892 to 5.8508. Of note the diagnostic yield was similar for ICCE category B,C &D (p=0.6356). On follow up a histological diagnosis of CD was made in 25 (30%) cases and was similar in both the ICCE + and ICCE – groups, 17/ 48 versus 8/34 (p=0.09).

Conclusion

ICCE criteria in our cohort predicted significant enteritis and CD. Each of the secondary ICCE categories performed similarly. Of interest is the significant rate of enteritis in patients not meeting the criteria, with similar rates of confirmed CD to the ICCE + cohort, suggesting these patients still warrant investigation with capsule and that the clinical features and presentation of small bowel CD is varied.

References

Mergener K, Ponchon T, Gralnek I et.al. Literature review and recommendations for clinical application of small bowel capsule endoscopy, based on a panel discussion by international experts. Consensus statements for small bowel capsule endoscopy. 2006/2007, Endoscopy 2007; 39: 895-909.

Introduction

Crohn's disease (CD) is a heterogeneous condition that can affect the entire gastrointestinal tract, with isolated small bowel (SB) involvement occurring in 20–30% of patients. According to ECCO and other international guidelines, the standard diagnostic approach for CD includes ileocolonoscopy and cross-sectional SB imaging. When these modalities yield inconclusive results, video capsule endoscopy (VCE) is recommended for evaluating SB mucosa. Despite negative findings on comprehensive evaluations, a significant proportion of patients continue to experience symptoms suggestive of CD. This study aimed to assess the long-term outcomes of patients with a negative comprehensive assessment for CD and a negative VCE study.

Aims & Methods

This retrospective cohort study was conducted at a large tertiary inflammatory bowel disease (IBD) center in Israel, serving a broad catchment area and providing VCE services for the entire national population insured by the largest Israeli health maintenance organization. Patients referred for VCE due to suspected CD and inconclusive endoscopy and cross-sectional imaging findings between 2008 and 2017 were included. Two individual capsule endoscopy readers revised all VCE studies. Longitudinal electronic medical records were analyzed to identify subsequent CD or alternative diagnoses. Clinical and laboratory data at the time of the index VCE were also evaluated.

Results

A total of 615 patients were included, of whom 354 (57.5%) were female, with a median age of 36 years (IQR: 27–55). CD was diagnosed in 192 patients (31.2%) based on the index VCE, with a median Lewis score (LS) of 900 (IQR: 450–1350). The remaining 423 patients (68.8%) had normal or minimal findings (LS <135) on VCE. This sub-cohort with negative VCE findings was further followed for a median duration of 8 years (IQR: 5–10; range: 3–12), corresponding to 3,042 patient years of observation. Notably, during follow-up, only 19 patients (4.5%) were diagnosed with CD; the majority based on clinical judgement alone (with no other objective findings), while one patient was diagnosed after a third VCE study. The median time to CD diagnosis was 1.5 years (IQR: 1–3) post-index VCE. Neither clinical symptoms nor basic laboratory results at the time of index VCE predicted CD diagnosis following the negative index VCE.

Conclusion

The incidence of CD diagnosis following a negative VCE study is exceptionally low, with most diagnoses occurring early after the index study. Patients with negative VCE findings may benefit from further diagnostic evaluation to investigate non-CD etiologies for their symptoms.

Disclosure

Iris Dotan: Consultation/advisory board: Abbvie, Arena, Cambridge Healthcare, Celltrion, Celgene/BMS, Ferring, Janssen, MSD, Neopharm, Pfizer, Rafa laboratories, Roche/Genentech, and Takeda; and Speaking/teaching: Abbvie, Celltrion, Celgene/BMS, Ferring, Falk Pharma, Janssen, MSD, Neopharm, Pfizer, Rafa laboratories, Roche/Genentech, Sandoz, and Takeda. Jacob E Ollech: reports institutional research grants from Pfizer. Henit Yanai: Advisory Committee or Review Panels: Takeda, Abbvie, Pfizer, Janssen, BMS, and Eli Lilli; Grant/Research Support: Pfizer; Speaking and Teaching: Abbvie, Pfizer, Takeda, Novartis, and BMS. . Irit Avni-Biron reports honoraria for lectures from AbbVie, Janssen and Takeda, Clinical research specialist, R&D clinical intelligence, Medtronic.
The remaining authors declare no conflicts of interest relevant to this article to disclose

Introduction

Severe Crohn's disease (CD) may progress to short bowel syndrome (SBS). Teduglutide stands as a validated treatment for SBS offering promising results for these patients.

Aims & Methods

This study aims to evaluate the performance of teduglutide in the subgroup of patients with SBS secondary to CD. We performed a systematic review in PubMed, Embase and Cochrane databases, searching for studies with patients with SBS and CD treated with teduglutide. The primary outcome was the reduction of parenteral support (PS). The secondary outcome was discontinuation of PS. The odds ratio (OR) was used for binary outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I² statistics.

Results

The meta-analyses included 4 studies and 77 patients. All studies evaluated PS reduction and teduglutide demonstrated a good performance (PS reduction in 79.94% of the patients; 95% CI 57.97% to 100.00%; I2=85%). Three studies (61 patients) evaluated PS discontinuation and teduglutide demonstrated a good performance too (PS discontinuation in 28.59% of the patients; 95% CI 17.43% to 39.75%; I2=0%).

Conclusion

Teduglutide is a good therapeutic option for patients with SBS in the subgroup of CD patients, improving PS reduction and discontinuation and leading to better quality of life of these patients.

References

1. Joly F, Seguy D, Nuzzo A, Chambrier C, Beau P, Poullenot F, et al. Six-month outcomes of teduglutide treatment in adult patients with short bowel syndrome with chronic intestinal failure: A real-world French observational cohort study. Clin Nutr Edinb Scotl. 2020 Sep;39(9):2856–62.
2. Kochar B, Long MD, Shelton E, Young L, Farraye FA, Yajnik V, et al. Safety and Efficacy of Teduglutide (Gattex) in Patients With Crohn’s Disease and Need for Parenteral Support Due to Short Bowel Syndrome-associated Intestinal Failure. J Clin Gastroenterol. 2017 Jul;51(6):508–11.
3. Sato T, Uchino M, Takeuchi J, Fujihira Y, Shimizu K, Yokoyama K, et al. Short-term clinical evaluation of teduglutide for patients with Crohn’s disease on home parenteral support for postoperative short bowel syndrome with intestinal failure. Clin Nutr Edinb Scotl. 2023 May;42(5):722–31.
4. Siu RK, Karime C, Hashash JG, Kinnucan J, Picco MF, Farraye FA. Improved Outcomes Associated With Teduglutide Use in Patients With Both Short Bowel Syndrome and Crohn’s Disease. Crohns Colitis 360. 2024 Jan;6(1):otae007.