Introduction

The terminal ileum stands out as the most frequently affected segment of the gastrointestinal tract in Crohn’s disease (CD). However, ileocolonoscopy (IC) may occasionally fail to fully explore this area. Notably, there is a lack of standardized quality criteria for IC in the context of ileal CD. Additionally, assessing inflammation activity only in the terminal ileum may lead to an underestimation of the overall ileal involvement. Capsule endoscopy (CE) offers a complete examination of both the entire terminal ileum and the remaining ileal segment.

Aims & Methods

This study presents the preliminary analysis of a retrospective study conducted at a single center. The primary outcome is the correlation between the total ileal activity, as assessed by CE, and the activity in the terminal ileum, as evaluated by IC. Furthermore, we explored the correlation between the results of these two examinations specifically concerning the evaluation of the terminal ileum. Patient inclusion criteria permitted a maximum time interval of 3 months between the two examinations. Activity measurement for CE was graded with the Lewis score of the third segment of the small intestine (Lewis-3S) and the Lewis score of the terminal ileum (Lewis-TI). For IC, the SES-CD index of the terminal ileum was collected. The study also includes an analysis of the correlation of endoscopic scores with biochemical markers (PCR, fecal calprotectin). Clinical, blood tests, and therapeutic data from medical records were systematically collected.

Results

A total of 18 patients with ileal CD underwent CE and IC. CE revealed terminal ileum activity in 14 out of 18 patients (78%), whereas IC detected activity in only 4 out of 18 patients (22%). Notably, no significant correlations between CE and IC scores were observed. A moderate to strong correlation was, however, identified between the two CE scores, Lewis-3S and Lewis-TI (⍴ 0.72 [0.31-0.94], p=0.001). The median length explored by IC was 15 [15-20] centimeters. Importantly, no correlation between endoscopic scores and biochemical parameters was observed, and no adverse events were documented.

Conclusion

In this preliminary analysis, despite the limited sample size, our findings indicate an underestimation of global ileal activity when measured by IC in comparison to CE examination.

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

Features and management of post operative recurrence (POR) of Crohn’s Disease (CD) after ileocecal resection (ICR) are well defined, but POR after colectomy is scarcely described.

Aims & Methods

Multicenter, nationwide, retrospective study promoted by the Spanish Working Group on Crohn's and Colitis (GETECCU). CD patients who underwent segmental colectomy (SC) or subtotal colectomy (STC) between 2012 and 2023 were included. Primary endpoint was clinical POR, defined as CD-related symptoms requiring salvage therapy despite POR prophylaxis. Secondary endpoints included endoscopic POR (anastomotic and/or perianastomotic CD-associated lesions at endoscopy), association between clinical and endoscopic POR, comparison of clinical and endoscopic POR-free survival among different types of colectomy, surgical recurrence (need for reoperation) depending on colectomy subtypes; and identification of factors associated with post-colectomy POR.

Results

224 patients were included: 157 (70%) underwent SC and 67 (30%) underwent STC. In the SC group, patients were older [44 (SD 15) vs 39 (SD 14) years old, p=0.01] and B3 phenotype was more frequent [68/157 (43%) vs 14/67 (21%), p = 0.003]. POR prophylaxis was prescribed in 119/157 (76%) SC patients and in 47/67 (70%) STC patients, with no significant differences regarding the choice of agent (main baseline characteristics of the study population are described in Table 1). The main indication for surgery was stenosing disease [both in SC group (83/157, 53%) and STC group (34/67, (51%)]. Median follow-up was 19.5 [3.7–67.9] months to clinical POR and 14.0 [5.9–54.1] months to endoscopic POR. Clinical POR developed in 60/157 (38%) in the SC group and 42/67 (63%) in the STC group (p = 0.001). Endoscopic evaluation was available in 190/224 patients (85%) [131/157 SC (83%) and 59/67 (88%) STC]; endoscopic POR was detected in 66/131 (50%) SC patients and 42/59 (71%) STC patients (p=0.012). Among patients with endoscopic POR, 76/108 (70%) also presented clinical POR: 43/66 (65%) patients in the SC group and 33/42 (79%) in the STC group (p=0.203). Clinical and endoscopic POR-free survival was higher for SC than for STC (p log-rank <0.05). Surgical recurrence occurred in 17/157 patients (11%) in the SC group and in 8/67 patients (12%) in the STC group (p=0.992). Multivariate stepwise Cox proportional hazards regression showed significant association of STC, smoking and myenteric plexitis with both clinical POR (HR 2.36, 95%CI [1.45 - 3.82]; HR 1.34, 95%CI [1.03 - 1,75] and HR 1.71, 95%CI [1.01 - 2.91] respectively) and endoscopic POR (HR 2.47, 95%CI [1.49 - 4.10], HR 1.36, 95%CI [1.03 - 1.79] and HR 1.83, 95% CI [1.01 - 3.29], respectively); and immunomodulator prophylaxis with endoscopic POR (HR 1.72, 95%CI [1.02 - 2.90]) (all p-values <.05).

Conclusion

POR remains common after colectomy in patients with CD. Clinical and endoscopic POR rates are higher following STC compared to SC in patients under similar prophylactic regimes. Although prospective research is still warranted, our data support favoring segmental resection of colonic CD when feasible.

Disclosure

J.L.R.G. has received financial support for traveling and educational activities or has received fees as a speaker from Abbvie, Kern Pharma, Janssen, Takeda, Pfizer, Lilly, Galapagos, Adacyte, Ferring, Tillotts Pharma, Faes Farma, Norgine and Casen. C.S.F. has received financial support for traveling and educational activities or has received fees as a speaker or consultant from Abbvie, Kern Pharma, Lilly, Ferring, MSD, Janssen, Takeda and Tillotts Pharma. YZ has received financial support for travelling and educational activities from or has served as an advisory board member for AbbVie, Adacyte, Alfasigma, Almirall, Amgen, Boehringer Ingelheim, Dr Falk Pharma, Faes Pharma, Fresenius Kabi, Ferring, Galapagos, Janssen, Johnson&Johnson, Kern, Lilly, MSD, Otsuka, Pfizer, Sanofi, Shire, Takeda, and Tillotts Pharma. The rest of the authors have no conflicts of interest to declare regarding this study.

Introduction

Capsule panendoscopy is increasingly used in Crohn's disease (CD), particularly in patients with extensive small bowel and colonic involvement. It offers a non-invasive, one-step evaluation of both segments, making it appealing for disease monitoring and treatment response. However, there is a need for validated scoring systems that objectively assess inflammatory activity in both the small bowel and the colon.

Aims & Methods

The aim of this study was to externally validate the Eliakim Score (Elk-S), developed to assess mucosal inflammation in CD by capsule panendoscopy. Patients referred for PillCam™ Crohn's examination at our institution were selected, and procedure data were collected retrospectively to calculate the Elk-S.

Results

A total of 72 patients were included, 62.5% female, with a mean age of 42±15 years. In 52 (72.2%) individuals, the indication for the procedure was suspected CD. Among them, the diagnosis was rejected in 38 cases, while in 14 cases, the diagnosis was established. There was a significant difference in mean Elk-S between the two groups (5.3±1.5 vs. 21.8±5.3, respectively; p<0.001). Capsule panendoscopy was used to evaluate inflammatory activity in 20 (27.8%) patients with CD. Treatment remained unchanged in 10 cases, while therapy was intensified in 10 patients, and there was a significant difference in mean Elk-S between the two groups (2.2±0.5 vs. 17.1±2, respectively; p<0.001). The Elk-S demonstrated an area under the ROC curve of 0.979 for the diagnosis of CD and 0.875 for predicting therapeutic escalation. An Elk-S ≥ 7 (Table 1) had a Sensitivity, Specificity, Negative Predictive Value, and Positive Predictive Value of 100%, 89.5%, 100%, 77.8%, respectively, for the diagnosis of CD. To determine the need for therapeutic intensification in patients with established CD, the same cut-off value showed a Sensitivity, Specificity, Negative Predictive Value, and Positive Predictive Value of 90%, 70%, 87.5%, 75%, respectively.

Conclusion

The Elk-S exhibited high accuracy in establishing the diagnosis of CD and was equally useful in predicting the need for therapeutic intensification in cases of established CD. The present study represents the first external validation of the Elk-S, demonstrating its effectiveness for assessing inflammatory activity via capsule panendoscopy of both the small bowel and colon.

References

Eliakim R, Yablecovitch D, Lahat A, et al. A novel PillCam Crohn’s capsule score (Eliakim score) for quantification of mucosal inflammation in Crohn’s disease. United Eur Gastroenterol J. 2020;8(5):544-551. doi:10.1177/2050640620913368

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

Endoscopy is still the gold-standard to assess disease activity in Crohn's disease (CD). Its invasiveness, acceptability and cost limit its use in the era of tight control and treat-to-target. Fecal calprotectin and intestinal ultrasound (IUS) are non-invasive alternatives to colonoscopy to assess disease activity. The objective of this study was to evaluate the performance of IUS and fecal calprotectin to assess mucosal healing in CD.

Aims & Methods

All consecutive CD patients who underwent colonoscopy for mucosal healing assessment and IUS and/or calprotectin within 4 weeks between September 2019 and April 2022 were included in a prospective cohort. Bowel wall thickness (BWT) and color doppler signal (CDS) were assessed on each segment. Endoscopic mucosal healing was defined by a CDEIS score < 3.

Results

A total of 153 patients were included, of whom 122 had endoscopic mucosal healing. Eighty-two (53.6%) were female, the median age and disease duration were respectively 36 years (IQR, 28-46) and 10 years (IQR, 4-19). Respectively 56 (56/120, 46.7%) and 93 (93/120, 77.5%) patients presented a BWT < 3 mm and an absence of CDS. The sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of BWT < 3 mm to predict endoscopic mucosal healing were 56%, 88%, 95% and 36% (patients misclassified as endoscopic mucosal healing 2.5%). The association of an absent of CDS with a normal BWT did not modify the performances. For a calprotectin < 250 µg/g , The Se, Sp, PPV and NPV were respectively 91%, 63%, 90% and 67% for (patients misclassified 8%). The association of a calprotectin < 250 µg/g, with a BWT < 3 mm and the absence of CDS increased the specificity and the PPV (Se 58%, Sp 95%, PPV 97%, VPN 43%, patients misclassified 1%).

Conclusion

Ultrasound is an efficient non-invasive tool to identify patients with Crohn's disease who have achieved endoscopic mucosal healing.