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.
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).
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.
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.
Crohn's disease (CD) is an IBD that can affect the entire gastrointestinal tract, the small bowel (SB) being the most commonly affected site.
CE can be utilized to assess various aspects of CD. It may provide confirmation of the diagnosis and assessment of the extent of disease in cases of suspected CD (sCD), while in established CD (eCD), it can be used to monitor disease activity, mucosal healing (MH), and postsurgical recurrence.
The diagnostic yield of CE for CD varies from 28% to 71%.
Between March 2003 and June 2015, 651 CE procedures were performed for various indications. Patients were excluded from the analysis if they had other SB diseases such as infectious disease, ischemia, vasculitis, tumor, or lymphoma. Finally, we retrospectively analyzed the medical records of patients who underwent CE in 57 cases of sCD and 14 cases of eCD. CE was not indicated for patients in whom obstructive symptoms or obstructive lesions were observed on radiological studies. Among all patients undergoing CE, 74.7% (53/71) underwent SBFT and/or abdominal CT for evaluating SB strictures. This study was approved by Soonchunhyang University Hospital Institutional Ethics Review Board (2015-07-025) and waived for informed consents.
Criteria used to define sCD were the presence of at least 2 of the following: abdominal pain or diarrhea, iron deficiency anemia, elevated ESR or CRP levels, hypoalbuminemia, extraintestinal manifestations, and family history of IBD. eCD was defined as previously diagnosed cases of CD that fulfilled established diagnostic criteria (presence of symptoms and a combination of endoscopic, pathologic, radiologic, and/or laboratory abnormalities).
CE was performed using either the PillCam™ SB1/SB2 (Given Imaging, Yokneam, Israel) or the MiroCam™ (Intro-Medic Co., Seoul, Korea). Prior to the procedure, patients underwent bowel preparation (using polyethylene glycol 1-2 L, Colyte™; Taejun Pharmacy, Seoul, Korea) and were kept NPO for at least 8 hours. Abdominal radiography was performed to confirm gastric retention of the capsule 2 hours after swallowing either the PillCam or the MiroCam. All images were reviewed by 2 board-certified endoscopists. The quality of CE images was classified as acceptable (excellent, good, or fair) or unacceptable (poor).
Statistical analysis was performed using PASW Statistics version 18.0 for Windows (SPSS Inc., Chicago, IL, USA). The results are presented as mean±SD or number (%). Continuous variables were analyzed using a two-tailed Student
The mean ages of the patients in the sCD and eCD groups were 45.8±15.9 and 37.4±17.0 years, respectively. Analysis of sex showed that 61.4% of patients in the sCD group and 78.6% of patients in the eCD group were male. In both groups, CE was performed in two-thirds of patients within 2 years of diagnosis of CD (sCD [85.9%] vs. eCD [64.2%]). A higher percentage of patients in the sCD group had a positive history of administration of NSAIDs, anticoagulants, or antiplatelet agents than in the eCD group (21.0% vs. 7.1%). At the time of CE, 71.4% of patients (10/14) in the eCD group were receiving treatment with only 5-aminosalicylic acid (5-ASA), and 28.6% (4/14) were receiving treatment with 5-ASA and steroids. A history of abdominal surgery was more common in the eCD group than in the sCD group (1.8% vs. 35.7%,
In the sCD group, the most common indication for CE for CD was initial diagnosis (54.4%), followed by differential diagnosis (45.6%). Twenty-five of 57 patients with sCD (43.8%) presented with overt obscure gastrointestinal bleeding. Only 11.5% of patients in the eCD group (14/122) underwent CE. Although 3 of 14 patients with eCD received SB and/or colon resection prior to CE owing to CD, all CEs in patients with eCD were performed for the assessment of disease activity. No significant differences were observed in the percentage of patients in the sCD and eCD groups with regard to the type of CE, quality of images, arrival rate of capsule at the cecum, and SB transit time. Capsule retention was only observed in 1 patient (7.1%) in the eCD group. The capsule was removed endoscopically via double-balloon enteroscopy, and an IM was added to the patient's treatment regimen.
In the sCD and eCD groups, the combined jejunal and ileal area represented the most common site of involvement (37.3% and 53.8%, respectively). Variable ulcerations were the most common findings in sCD (41.2%) and eCD (57.1%). Typical longitudinal ulcers were present in 23.5% and 14.3% of patients with sCD and eCD, respectively. The proportions of 14 patients with eCD with B1, B2, and B3 disease at diagnosis were 71.4%, 28.4%, and 7.1%, respectively. The proportions of patients with L1, L2, L3, L4, and L3+L4 disease were 28.6%, 28.6%, 14.3%, 7.1%, and 21.4%, respectively. Following CE, the location of CD was modified in 64.2% of patients (from L1 to L1+L4, n=4; from L2 to L2+L4, n=3; from L3 to L3+L4, n=2). The concordance rates between CE and SBFT/abdominal CT were 36.8%/20.0% and 33.3%/16.7% in the sCD and eCD groups, respectively; these findings were not significant.
Of the 57 patients with sCD, 28.1% (16/57) were diagnosed with CD on the basis of CE findings; other diagnoses included tuberculous enteritis, NSAID-induced enteropathy, and other enteritis (
The majority of patients in the sCD group (70.2%) were treated conservatively, while specific medications were initiated in 28.1% (n=14, 5-ASA; n=1, 5-ASA and steroid; n=1, anti-TB medication), and potentially disease-causing drugs (NSAIDs) were terminated for 1.8% of patients. In the eCD group, therapy was retained for 57.1% of patients (n=3, 5-ASA) or specific medication was added and/or increased (n=4, addition of steroid; n=1, dose increase of 5-ASA and addition of steroid), while 14.2% of patients were referred for surgery owing to obstructive symptoms following CE. Nevertheless, there were no dominant obstructive lesions on SBFT. The performance of surgery after CE was not associated with CE retention in any case. The final pathology revealed chronic transmural inflammation with granuloma, consistent with CD. Therapeutic strategies were changed for 70.2% of patients (40/57) in the sCD group and 50% of patients (7/14) in the eCD group on the basis of CE findings. Treatment results are summarized in
We investigated practice patterns of CE use in Korea and the clinical impact of CE in patients with CD and arrived at 3 main conclusions. First, in actual practice, we found that generally, CE was not performed for patients with eCD. Second, approximately one-fourth of patients with sCD were diagnosed with CD on the basis of CE findings. Third, therapeutic strategies were changed in >50% of patients with sCD or eCD based on the results of CE.
In Korea, the incidence and prevalence of CD are increasing rapidly.
In the present study, the most common indication for CE in patients with CD was to diagnose CD. In a meta-analysis comparing CE with SBFT, CTE, and MR enterography (MRE) in sCD, although there was no significant difference in diagnostic yield between CE and MRE (weighted incremental yield [IY]=7%, CE vs. MRE 50% vs. 43%), the weighted IY of CE was significantly superior to that of SBFT (weighted IY=32%, CE vs. SBFT 52% vs. 16%) and CTE (weighted IY=47%, 68% vs. 21%).
In the present study, only ~10% of the total group of patients with eCD underwent CE to assess disease extent and activity. In clinical practice, we can deduce that CE is not generally performed for the assessment of disease extent and activity, MH, or postoperative recurrence in patients with eCD. According to a previous study to assess MH using the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) in patients with SB CD beginning treatment with biologics or IMs, up to 30% of patients showed MH at assessment 12 weeks after the initiation of treatment.
In the current study, we also found that CE was not performed for the assessment of MH or postoperative recurrence in patients with eCD, possibly owing to the risk of capsule retention, as it is relatively common for patients with eCD to have SB strictures, which are often considered a contraindication to CE.
CE can play an important role in aiding decision-making regarding therapy in patients with CD. According to a previous study, CE findings resulted in altered management plans for 90% of patients with sCD and 73% of patients with eCD.
The present study has several limitations. First, this study was a retrospective analysis and, as a single-center study, had a relatively small patient number. Second, a selection bias may have occurred because the assessment of patients with sCD and eCD was limited to those undergoing CE, which could limit the strength of our conclusions. Third, although previous studies have described CE criteria for the diagnosis of CD (which we adapted for our study), diagnostic criteria for CE in patients with sCD remain unclear and subjective. It is difficult to distinguish TB or NSAID-induced enteropathy from CD because each of these can exhibit various inflammatory lesions and/or ulcers during CE. However, we attempted to perform the diagnoses as accurately as possible after integrating clinical manifestations, laboratory tests, and disease course based on CE findings. Prospective, multicenter studies are needed to more objectively determine CE-based diagnostic criteria for CD. Despite these limitations, we believe that the present study is valuable because it provides an analysis of the current practice patterns of CE use in Korea and highlights the scope of the expanded indications for the use of CE in the management of CD and the clinical significance of CE findings for patients with CD.
In conclusion, the most common indication for CE in CD was for the initial diagnosis, and CE was not generally performed in patients with eCD in clinical practice. CE appears to be an effective diagnostic modality for the evaluation of sCD, as well as a useful tool in the determination of therapeutic strategies for patients with sCD and those with eCD.
Characteristic | sCD | eCD | |
---|---|---|---|
No. of patients | 57 | 14 | |
Age (yr) | 47 (16–75) | 29 (21–69) | |
Male sex | 35 (61.4) | 11 (78.6) | 0.351 |
Disease duration <2 yr | 49 (85.9) | 9 (64.2) | 1.000 |
Medication usea | 12 (21.0) | 1 (7.1) | 0.439 |
History of abdominal surgery | 1 (1.8) | 5 (35.7) | 0.001 |
Appendicitis | 0 | 2 | |
Small bowel resection | 0 | 1 | |
Colon resection | 1 | 1 | |
Small bowel and colon resection | 0 | 1 | |
Laboratory test | |||
Leukocyte (/µL) | 5,950 (1,600–16,000) | 6,800 (4,000–11,900) | 0.533 |
Hemoglobin (g/dL) | 10.3 (5.0-15.0) | 10.6 (7.0-15.0) | 0.557 |
Platelet (103/µL) | 253 (105–463) | 279 (174–523) | 0.202 |
ESR (mm/h) | 16.5 (1–116) | 13.5 (2–49) | 0.190 |
CRP (mg/dL) | 0.17 (0–10.20) | 0.13 (0.02–7.50) | 0.847 |
Albumin (g/dL) | 3.9 (2.1–5.2) | 4.1 (1.6–4.6) | 0.702 |
Concordance rate between CE and SBFT | 7/19 (36.8) | 1/3 (33.3) | 0.197 |
Concordance rate between CE and abdominal CT | 8/40 (20.0) | 1/6 (16.7) | 0.775 |
Values are presented as median (range) or number (%).
aMedication use means history of administration of NSAIDs, anticoagulants, or antiplatelet agents.
sCD, suspected CD; eCD, established CD; CE, capsule endoscopy; SBFT, small bowel follow-through.
sCD (n=57) | eCD (n=14) | ||
---|---|---|---|
Type of CE | 0.084 | ||
PillCam (SB1) | 25 (43.9) | 10 (71.4) | |
PillCam (SB2) | 21 (36.8) | 1 (7.1) | |
MiroCam | 11 (19.3) | 3 (21.4) | |
Acceptable quality of images | 47 (90.4) | 11 (100.0) | 0.576 |
Complete SB evaluation | 41 (77.8) | 7 (58.3) | 0.271 |
Transit time (min) | 377±149 | 310±118 | 0.248 |
CE retention | 0 | 1 (7.1) | 0.197 |
Values are presented as number (%) or mean±SD.
sCD, suspected CD; eCD, established CD; CE, capsule endoscopy; SB, small bowel.
sCD (n=57) | eCD (n=14) | ||
---|---|---|---|
Site of involvementa | 0.662 | ||
Jejunum | 12 (23.5) | 2 (15.4) | |
Ileum | 18 (35.3) | 4 (30.8) | |
Jejunum+ileum | 19 (37.3) | 7 (53.8) | |
Duodenum | 2 (3.9) | 0 | |
Type of injury | 0.524 | ||
Normal | 0 | 2 (14.3) | |
Aphthous ulcer | 2 (11.8) | 1 (7.1) | |
Longitudinal ulcer | 4 (23.5) | 2 (14.3) | |
Cobblestone appearance | 0 | 0 | |
Inflammatory polyp | 1 (5.9) | 0 | |
Fistula | 0 | 0 | |
Variable ulcer | 7 (41.2) | 8 (57.1)b | |
Variable ulcer+stricture | 2 (11.8) | 1 (7.1) | |
Variable ulcer+inflammatory polyp | 1 (5.9) | 0 |
Values are presented as number (%).
aRegardless of complete SB evaluation of CE, the sites of observed lesions are described.
bIn CE findings, 2 patients who received surgery after CE showed variable ulcers.
sCD, suspected CD; eCD, established CD.
sCD (n=57) | eCD (n=14) | |
---|---|---|
Treatment modality | ||
Conservative treatment | 40 (70.2) | 1 (28.6) |
Specific medication | 16 (28.1) | 8 (57.1) |
Maintain | 0 | 3 |
Add | 16 | 5 |
Drug discontinuation | 1 (1.8) | 0 |
Operation | 0 | 2 (14.2) |
Therapeutic plan adjustment | 40/57 (70.2) | 7/14 (50.0) |
Values are presented as number (%).
sCD, suspected CD; eCD, established CD.