Capsule endoscopy in the diagnosis and management of inflammatory bowel disease

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Conventional radiology

Because small intestinal Crohn's disease has been traditionally difficult to visualize; contrast small bowel radiography remains the main diagnostic imaging modality [1]. There is not a single pathognomonic radiographic feature that defines Crohn's disease. Rather, the radiologic diagnosis is based on subjective interpretations that takes into consideration a range of findings such as aphthous ulcers, deep ulcerations, mucosal cobblestoning, skip lesions, fissures, fistulas, strictures, and

Serologic diagnosis of Crohn's disease

Two of the principle symptoms of Crohn's disease are chronic abdominal pain and diarrhea, which are also commonly seen in irritable bowel syndrome [10]. The number of individuals afflicted with these symptoms make it impractical to work up every potential patient with small bowel series, upper endoscopy, and colonoscopy. It is even more difficult to investigate patients without any upper gastrointestinal or colonic lesions because of the technical difficulty in accessing the mid- and distal

Are conventional studies adequate in evaluating small bowel Crohn's disease?

In spite of the large arrays of imaging and serologic studies for small bowel Crohn's disease, there are still many case scenarios in which a more sensitive imaging modality is needed. Patients who have well controlled ulcerative colitis but experience significant symptoms should be screened for small bowel Crohn's disease. These symptoms include unexplained hematochezia or melena, abdominal pain, diarrhea, or B12 deficiency. Likewise, patients with quiescent Crohn's colitis who continue to

Concerns about performing capsule endoscopy on Crohn's patients

Capsule endoscopy was approved by the Food and Drug Administration to study the small intestine in the United States in August of 2001. One of its contraindications is intestinal obstruction, which is obviously a major concern for Crohn's disease. It has been reported that intestinal obstruction occurs in 35% to 54% of Crohn's disease. [13]. If a capsule is stuck within the stricture of a Crohn's lesion, it could lead to acute intestinal obstruction. Even if there is no obstructive symptoms, a

Patient 1

The author's experience with capsule endoscopy for Crohn's disease related issues began with a young woman with a known history of ulcerative colitis and persistent abdominal pain in spite of quiescent colitis. Her capsule study was negative and she was subsequently reassured and managed for other functional abdominal pain without further problems.

Patient 2

A woman with Crohn's disease was studied for severe mid abdominal pain despite negative upper endoscopy, colonoscopy, and small bowel series. It was

Current clinical experience

There are perhaps 20 preliminary studies on capsule endoscopy for Crohn's disease that have been presented at the various international meetings. Virtually all of these studies reported on less than 50 patients but all showed some evidence that capsule endoscopy could become useful in the diagnosis and management of small bowel Crohn's disease. The first report on the usefulness of capsule endoscopy for Crohn's disease was published recently. Fireman et al [15] performed the study on 17

Appearance of Crohn's lesions on capsule endoscopy

Using capsule endoscopy to diagnose small intestinal Crohn's disease can be challenging, because the small bowel lining has never been visualized in this manner. The natural assumption is that the typical ulcers, erosions, and inflammation seen in the terminal ileum and duodenum by conventional endoscopy would appear the same in the small bowel on capsule endoscopy. However, this assumption cannot be taken for granted without corroborating evidence on conventional endoscopy and perhaps even

Is capsule endoscopy better than barium small bowel series in diagnosing Crohn's lesions?

Fireman's study [15] provided the initial insight that capsule endoscopy might be superior to the conventional imaging modalities in diagnosing Crohn's enteritis. Costamagna et al [20] performed sequential barium small bowel follow through and capsule endoscopy on 22 patients suspected of having small bowel diseases. Capsule endoscopy was found to be superior to small bowel radiographs in identifying mucosal pathologies. In this study, only 20% of the radiographic studies was positive, whereas

Is capsule endoscopy better than push enteroscopy in diagnosing Crohn's disease?

Crohn's disease is traditionally a distal small bowel disease and therefore places push enteroscopy at a disadvantage. There is no published report comparing push enteroscopy and capsule enteroscopy for this condition. However, Ell et al [21] performed enteroclysis, mesenteric angiography, bleeding scintigraphy, push enteroscopy, and capsule endoscopy on 32 patients referred for chronic obscure gastrointestinal bleeding. Two of the patients had chronic IBD causing the bleeding, whereas these

Is capsule endoscopy better than serologic markers in diagnosing Crohn's disease?

Serologic markers are generally regarded as specific (> 90%) IBD but lacking the sensitivity (50–70%) to do large scale screening [23], [24]. Therefore, they are primarily reserved to test individuals with significant and suspicious symptoms. When capsule endoscopy first became available, the author was uncertain if this test was sensitive in detecting small intestinal Crohn's disease, clinically active Crohn's disease, or not at all. One obvious question to the author was whether capsule

Incidental findings of small bowel ulcers suggestive of Crohn's disease

Crohn's disease is usually thought of as a symptomatic condition with presenting symptoms consisting of abdominal pain, anemia, weight loss, or diarrhea. It is rarely considered the cause of obscure gastrointestinal bleeding without other clinical clues. Of 13 patients referred for obscure gastrointestinal bleeding, Costamagna [20] found 1 case of distal ileal ulcers that was suspicious for Crohn's disease. Likewise, Ell [21] found 2 cases of inflammatory small bowel disease among 32 patients

Distribution of small bowel Crohn's disease based on capsule endoscopy

Limited by the inability to directly visualize most of the small intestine, the author's current knowledge of disease distribution is mostly based on barium small bowel series and retrograde ileoscopy. These two procedures bias the author's findings toward terminal ileal disease and obvious pathologies. Capsule endoscopy examinations are likely more objective and provide new insights into the true distribution of small bowel lesions. The author examined his patients who had complete small bowel

Capsule endoscopy may produce findings that alter disease management

Using capsule endoscopy to make diagnosis and guide therapy of intestinal Crohn's disease is a new concept. One's enthusiasm toward this technology must rest on whether the findings would influence disease management and outcomes. In a preliminary, uncontrolled, retrospective study, the author reported his experience on the first 50 patients suspected of small bowel Crohn's disease [16]. The capsule reader was unaware of the clinical and therapeutic information of these patients. Small bowel

Future issues regarding capsule endoscopy for Crohn's disease

The author's preliminary data suggest that capsule endoscopy will play an important role in the diagnosis and management of Crohn's disease. Besides having to confirm this data with larger and controlled studies, many issues remain to be addressed. Until now, Crohn's disease has been diagnosed somewhat subjectively after combining positive findings along with exclusion of other etiologies. Unless capsule endoscopy can identify pathognomonic features of Crohn's disease, it may become just

Integration of capsule endoscopy for Crohn's disease in the clinical setting

Capsule endoscopy has enormous potential in shaping the future management algorithm related to Crohn's disease. Its potential impact in the diagnosis and management of IBD may be even more significant than for evaluation of gastrointestinal bleeding. The role of capsule endoscopy in Crohn's disease may involve the entire spectrum of disease management, ranging from diagnosing to monitoring of disease activity and, hypothetically, surveying for cancer development. Although many potential

Summary

Capsule endoscopy was originally developed to detect small bowel sources of gastrointestinal bleeding. Barely 18 months old, this technology has now found a new and potentially more important indication in the diagnosis and management of small bowel Crohn's disease. Early experiences suggest that it is superior to currently available imaging modalities and therefore an ideal test to diagnose Crohn's disease. In the author's experience, capsule endoscopy has already helped elucidate new

Acknowledgements

The author thanks Dr. Waleed Shindy and Jan Daniels for offering their assistance in the preparation of this manuscript.

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