Usefulness of ultrasonography for small intestinal evaluations in pediatric Crohn's disease.

BACKGROUND: Small bowel capsule endoscopy (SBCE) for Crohn's disease is useful; however, its use has some limitations, such as invasiveness when endoscopic assistance is required in patients who cannot swallow the capsule, and the burden of interpretation on a physician. In contrast, intestinal ultrasonography (IUS) is a non-invasive modality for children. The purpose of this study is to evaluate the accuracy of IUS for pediatric patients with established Crohn's disease. METHODS: Small bowel capsule endoscopy and IUS findings from the same period in pediatric patients with established Crohn's disease were analyzed retrospectively. First, we compared the Lewis score (LS), small bowel endoscopic activity, and IUS findings by small bowel wall thickness (SBWT) and mesenteric lymph node size (MLNS). Second, we compared the performance of IUS findings with those of some biomarkers. RESULTS: In 22 procedures, SBWT and MLNS were correlated with LS (r = 0.52, P < 0.05, and r = 0.45, P < 0.05, respectively). Small bowel wall thickness, erythrocyte sedimentation rate, and fecal calprotectin levels had the highest accuracy (81.8%, 81.8%, and 81.8%, respectively). The combination of SBWT and MLNS had the highest positive predictive value and negative predictive value (100% and 83.3%, respectively). CONCLUSIONS: Intestinal ultrasonography findings, including SBWT and MLNS, are useful for monitoring small bowel lesions in pediatric patients with established Crohn's disease. We suggest first evaluating small bowel inflammation by IUS in pediatric patients with Crohn's disease before SBCE because IUS is less invasive than SBCE.

Simplify to improve in capsule endoscopy - TOP 100 is a swift and reliable evaluation tool for the small bowel inflammatory activity in Crohn's disease.

Background: Capsule endoscopy is a widely recognized method to study the small bowel, including in patients with Crohn's disease (CD). The Lewis score (LS) is a valuable tool in this setting, able to assess inflammatory activity. TOP100, a new software tool of the RAPID Reader®, emerged to assist in the time-consuming capsule reading process, by automatically selecting 100 images that will most likely contain abnormalities.Aim: Evaluate the agreement between TOP100 and classic reading (CR) in determining LS in the setting of CD.Methods: Retrospective study including consecutive patients undergoing small bowel capsule endoscopy (SBCE) for suspected or established CD. One experienced reader performed CR and calculated the LS. Another experienced reader, blinded to the CR results, reviewed all SBCE videos using TOP100 and calculated the LS.Results: One hundred and fifteen patients were included. SBCE detected significant inflammatory activity (LS ≥135) in 64 patients (55.7%). We verified a strong agreement between the two methods of capsule reading (Kappa = 0.83, p < .001), with an agreement on 89.6% of the cases. The agreement was superior in moderate-to-severe inflammatory activity (Kappa = 0.92, p < .001). All cases of moderate-to-severe activity detected by CR were identified by TOP100 as significant inflammatory activity. A good agreement was verified in all tertiles (p < .001).Conclusions: Although the classical review of the entire video remains the gold standard, the TOP100 has been shown to be a useful tool in assisting the reader in a prompt calculation of LS, in particular for identifying patients with moderate-to-severe inflammatory disease.

Comparison of Lewis Score and Capsule Endoscopy Crohn's Disease Activity Index in Patients with Crohn's Disease.

BACKGROUND/AIMS: Small bowel capsule endoscopy (SBCE) is used to visualize mucosal inflammatory changes in the small intestine of patients with Crohn's disease (CD). The Lewis score (LS) and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) are used to evaluate the visualized images. We determined the score disagreement between LS and CECDAI in patients with CD. METHODS: We evaluated 184 SBCE procedures in 102 CD patients with small bowel lesions. Patients were classified according to the Montreal classification. LS and CECDAI were calculated, and cases with disagreement between the two scores were identified. We investigated the characteristics of disagreement, and analyzed the relationships with the Crohn's Disease Activity Index (CDAI) and C-reactive protein. RESULTS: LS (504 ± 1160) correlated strongly with CECDAI (6 ± 5.4) (Spearman's rank correlation coefficient ρ = 0.81, p < 0.0001). LS values of 135 and 790 were equivalent to CECDAI values of 4.9 and 6.9, respectively. The inflammatory changes by LS were significantly observed in several tertiles in the CECDAI discrepancy group (LS < 135, CECDAI ≥ 4.9) compared with the normal agreement group (LS < 135, CECDAI < 4.9) (p < 0.0001). In both groups, CDAI was also significantly different between Montreal L1 and L3 groups (p = 0.0232, p = 0.0196, respectively). LS inflammation score was 0 in six cases in the LS discrepancy group (LS ≥ 135, CECDAI ≤ 4.9, n = 10); the high LS scores were in patients with high stricture scores. CONCLUSIONS: Discrepancies between the LS and CECDAI scores were observed in some patients. Cases with high CECDAI alone exhibited extensive inflammation and high disease activity (clinical symptoms and biomarker levels). CECDAI seems to better reflect active intestinal inflammation than LS.

Correlation of the endoscopic findings for small and large bowels in pediatric patients with established Crohn's disease.

Small bowel capsule endoscopy can detect subtle mucosal lesions in pediatric patients with Crohn's disease, and our aim was to evaluate its application in established ileocolonic Crohn's disease. Colonic inflammation was evaluated with the colonic Simple Endoscopic Score for Crohn's Disease (SES-CD) (excluding the score of the terminal ileum). Small bowel inflammation was evaluated with the Lewis score and/or Capsule Endoscopy Crohn's Disease Activity Index (CECDAI). A Lewis score <135 was defined as small bowel inactive. A colonic SES-CD of 0 (colonic inactive group) was observed in 22/42 procedures (52.4%), and active small bowel lesions were observed in 11/22 procedures (50.0%). The Lewis score was lower in the colonic inactive group compared to the colonic active group. Correlations between the colonic SES-CD, the Lewis score and CECDAI were weak. The Lewis score and CECDAI in the colonic inactive group had significant correlation with fecal calprotectin levels. We suggest that Crohn's disease patients without both colonic active lesions and elevation of fecal calprotectin levels may not need to receive small bowel capsule endoscopy due to low incidence of lesions in small bowel.

Comparison of Small Bowel Lesions Using Capsule Endoscopy in Ulcerative Colitis and Crohn's Disease: A Single-Center Retrospective Analysis.

BACKGROUND: Capsule endoscopy (CE) has allowed the characterization of small bowel lesions. However, small bowel lesions in ulcerative colitis (UC) have not been elucidated and no studies have compared between UC and Crohn's disease (CD). AIM: The objective of this study was to investigate the small bowel lesions in UC, and to characterize UC lesions by comparison with CD. METHODS: Subjects comprised 54 UC patients and 39 CD patients who underwent CE. We retrospectively investigated characteristics of small bowel lesions in UC. We also compared endoscopic findings and degree of inflammation between UC and CD. RESULTS: The incidence of small bowel lesions in UC was 27.8%. The group with small bowel lesions exhibited higher endoscopic activity in the colon than without small bowel lesions (p = 0.002). Comparing small bowel lesions between UC and CD, significantly more ulcerative lesions, notched appearance, longitudinal tendency of lesions, and cobblestone appearance were seen in CD. The Lewis score was significantly higher in CD than UC in the second and third tertiles (205 ± 379 vs. 73 ± 223, p = 0.01; 358 ± 449 vs. 105 ± 333, p < 0.001). CONCLUSIONS: Small bowel lesions in UC were linked to colonic activity. UC and CD differ in terms of the morphology and distribution of small bowel lesions.

Evaluation and comparison of capsule endoscopy scores for assessment of inflammatory activity of small-bowel in Crohn's disease.

INTRODUCTION: Capsule endoscopy (CE) has the highest sensitivity in the evaluation of small-bowel mucosa in Crohn's disease (CD). Recent guidelines recommend the use of validated CE scores to assess small-bowel inflammatory activity in CD. Lewis score (LS) and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) are the currently available validated scores, but comparative studies are scarce. Moreover, correlation of these endoscopic scores with biomarkers and clinical activity is lacking. This study aims to compare LS with CECDAI, to determine cutoff values for CECDAI similar to those of LS (135-790), and to correlate LS and CECDAI with biomarkers and symptoms. STUDY: All patients with CD who underwent CE between March/2010 and February/2016 were included. LS and CECDAI were determined after analysis of each CE. In patients with small-bowel CD, C-reactive protein (CRP) and Harvey-Bradshaw index (HBI) were evaluated. STATISTICAL ANALYSIS: descriptive statistics, Spearman's correlation coefficient and linear regression analysis. SIGNIFICANCE: p<0.05. RESULTS: Fifty-three patients were included and the mean values obtained for LS were 1147±1453, CECDAI 11.3±6.9, CRP 0.92±1.5mg/dL and HBI 2.4±2.8. There was a very strong correlation between LS and CECDAI (rs=0.878; p<0.0001) and thresholds values of 135-790 in LS corresponded to 7.7-10.3 cutoff values in CECDAI, respectively. Neither CRP correlated with LS (rs=0.068; p=0.72) or CECDAI (rs=-0.004; p=0.98), nor HBI with LS (rs=-0.15; p=0.40) or CECDAI (rs=-0.10; p=0.23). CONCLUSION: Correlation between the two CE activity scores was very strong, with LS thresholds of 135-790 corresponding to CECDAI values of 7.7-10.3. HBI and CRP had no correlation with CECDAI and LS.

Association Between Fecal Calprotectin Levels and Small-bowel Inflammation Score in Capsule Endoscopy: A Multicenter Retrospective Study.

BACKGROUND: Accurate inflammation reporting in capsule endoscopy (CE) is important for diagnosis and monitoring of treatment of inflammatory bowel disease (IBD). Fecal calprotectin (FC) is a highly specific biomarker of gut inflammation. Lewis score (LS) was developed to standardize quantification of inflammation in small-bowel (SB) CE images. GOALS: Multicenter retrospective study aiming to investigate correlation between LS and FC in a large group of patients undergoing CE for suspected or known small-bowel IBD, and to develop a model for prediction of CE results (LS) based on FC levels. STUDY: Five academic centers and a district general hospital offering CE in UK, Finland, Sweden, Canada, and Israel. In total, 333 patients were recruited. They had small-bowel CE and FC done within 3 months. RESULTS: Overall, correlation between FC and LS was weak (r s: 0.232, P < 0.001). When two clinically significant FC thresholds (100 and 250 µg/g) were examined, the r s between FC and LS was 0.247 (weak) and 0.337 (moderate), respectively (P = 0.307). For clinically significant (LS ≥ 135) or negative (LS < 135) for SB inflammation, ROC curves gave an optimum cutoff point of FC 76 µg/g with sensitivity 0.59 and specificity 0.41. LIMITATIONS: Retrospective design. CONCLUSIONS: LS appears to show low correlation with FC as well as other serology markers of inflammation. FC does not appear to be a reliable biomarker for significant small-bowel inflammation. Nevertheless, FC level ≥ 76 µg/g may be associated with appreciable visual inflammation on small-bowel CE in patients with negative prior diagnostic workup.

Clinical value of capsule endoscopy for detecting small bowel lesions in patients with intestinal Behçet's disease.

BACKGROUND AND AIM: To evaluate the clinical value of capsule endoscopy (CE) in patients with intestinal Behçet's disease (BD). METHODS: The present study was a case-control pilot study conducted in intestinal BD patients and healthy volunteers. A total of 19 patients with intestinal BD (intestinal BD group) and 19 healthy volunteers (control group) matched for age and sex were enrolled. Frequency, number of small bowel lesions per subject, and Lewis score were comparatively evaluated between the two groups. RESULTS: Of the 19 patients with intestinal BD, 18 (94.7%) had reddened lesions, 15 (78.9%) had erosions, and nine (47.4%) had ulcers. There were significant differences in the frequency of reddened lesions (P < 0.0001), erosions (P < 0.0001) and ulcers (P = 0.0011) between the two groups. The difference in the number of small bowel lesions between the two groups was also statistically significant. The median Lewis score in the intestinal BD group was significantly higher than that in the control group (intestinal BD group 237 (0-768) vs. control group 8 (0-135); P < 0.0001). Analysis according to the location in the small bowel revealed that the frequency of ulcers tended to increase towards the distal intestine. CONCLUSION: This is the first CE study conducted to examine small bowel involvement in intestinal BD patients. Our results suggest that CE evaluation is necessary, in addition to colonoscopy, in all intestinal BD patients.

Capsule endoscopic findings correlate with fecal calprotectin and C-reactive protein in patients with suspected small-bowel Crohn's disease.

OBJECTIVE: Capsule endoscopy (CE) is a sensitive method for detecting inflammatory lesions in the small bowel. Such lesions may be due to Crohn's disease but also to other causes and a histological diagnosis may be difficult to achieve in the small bowel. The aim of the study was to find a possible correlation between capsule endoscopic findings, biochemical parameters, and symptoms in patients with suspected or known small-bowel Crohn´s disease. MATERIALS AND METHODS: Thirty patients with inflammatory lesions in the small bowel diagnosed by CE were included. CE findings of inflammation were graded using the Lewis score. C-reactive protein (CRP) and fecal calprotectin were used as biochemical parameters. Symptoms were graded using the Harvey-Bradshaw index. The patients were followed up after 9 months with a second CE, CRP, fecal calprotectin, and Harvey-Bradshaw index. RESULTS: There was a significant persistent correlation between endoscopic inflammation and fecal calprotectin (p = 0.003 at inclusion and p < 0.001 at follow-up). CRP was correlated to endoscopic inflammation at inclusion (p = 0.006), but not at follow-up. Symptoms were not correlated with endoscopic inflammation. CONCLUSION: Inflammatory lesions in the small bowel diagnosed by CE in patients with suspected Crohn´s disease are correlated to fecal calprotectin and CRP, but not to symptoms.

Fecal calprotectin diagnostic level gradient along the small bowel in patients with Crohn's disease.

BACKGROUND AND AIMS: Fecal calprotectin (FC) is known to be a sensitive biomarker of colonic inflammation but to a lesser degree of small bowel (SB) inflammation. Moreover, data on FC's diagnostic levels in different SB segments are scarce. We aimed to examine FC's diagnostic levels along the SB-axis in CD. METHODS: This was a post-hoc aggregated analysis of five prospective studies of adult CD patients, who underwent FC testing and SB video capsule endoscopy (VCE). Lewis score (LS) inflammation in different SB segments was tested for correlation with FC level after exclusion of colonic disease. The diagnostic levels of FC for SB inflammatory topographical-gradient were assessed using a receiver operating characteristic. RESULTS: 214 patients were included (age:30 [24-43] year-old, males-57%). For a similar SB inflammatory-activity (LS≥135), FC levels incrementally increased from proximal to distal SB segments (63 [30-121] versus 190 [78-549], p=0.005) and from distal SB segment to the colon (190 [78-549] versus 542 [185-1000], p=0.010). The best FC cutoffs to identify isolated mild proximal/distal SB-inflammation (LS≥135) were 77µgg and 123µgg, respectively. A cutoff of 234µgg was best to detect more significant proximal inflammation (LS≥350) when only mild distal SB-inflammation was present. In sensitivity analyses, this proximal-to-distal FC gradient was maintained when LS≥350 and LS≥790 were used as the inflammatory reference-values. Unlike FC, the magnitude of CRP elevation was unrelated to the topography of inflammation along the SB-axis. CONCLUSIONS: FC may serve as a topographical biomarker of CD-activity, with its sensitivity to identify mucosal inflammation increases from proximal to distal SB segments.

Middle small-bowel segment Lewis score may predict long-term outcomes among patients with quiescent Crohn's disease.

Background: Video capsule endoscopy (VCE) has been proven to accurately diagnose small-bowel inflammation and predict flares among patients with quiescent Crohn's disease (CD). However, data regarding its predictive role in this population over an extended follow-up are scarce. Objectives: To predict clinical exacerbation and to assess the yield of Lewis score in identifying CD patients with future clinical exacerbation during an extended follow-up (>24 months). Design: A post hoc analysis study. Methods: Adult patients with quiescent small-bowel CD who were followed with VCE, inflammatory biomarkers and magnetic resonance enterography in a prospective study (between 2013 and 2018). We extracted extended clinical data (up to April 2022). The primary composite outcome (i.e. clinical exacerbation) was defined as intestinal surgery, endoscopic dilation, CD-related admission, corticosteroid administration, or biological/immunomodulator treatment change during follow-up. Results: Of the 61 patients in the study [median age 29 (24-37) years, male 57.4%, biologic treatment 46.7%], 18 patients met the primary outcome during an extended follow-up [median 58.0 (34.5-93.0) months]. On univariable analysis, complicated [hazard ratio (HR) 7.348, p = 0.002] and stricturing disease phenotype (HR 5.305, p = 0.001) were associated with higher risk for clinical exacerbation during follow-up. A baseline VCE middle small-bowel segment Lewis score (midLS) ⩾ 135 identified patients with future exacerbation [AUC (area under the curve) 0.767, 95% confidence interval (CI) 0.633-0.902, p = 0.001, HR 6.317, 93% negative predictive value], whereas the AUC of the conventional Lewis score was 0.734 (95% CI: 0.589-0.879, p = 0.004). Sensitivity analysis restricted to patients with either complicated (n = 34) or stricturing (n = 26) disease phenotype revealed that midLS still predicted clinical exacerbation during follow-up (AUC 0.747/0.753, respectively), in these patients. Conclusion: MidLS predicts treatment failure in quiescent CD patients (median follow-up of 5 years) independently of disease phenotype.

Serum Leucine-Rich Alpha-2 Glycoprotein in Quiescent Crohn's Disease as a Potential Surrogate Marker for Small-Bowel Ulceration detected by Capsule Endoscopy.

Background: Small bowel (SB) lesions in quiescent Crohn's disease (CD) are sometimes not identified by clinical activity or existing markers. We investigated the usefulness of a novel biomarker, leucine-rich α2-glycoprotein (LRG), for screening for the presence of SB ulcerative lesions detected by small-bowel capsule endoscopy (SBCE). Methods: We examined patients with a Crohn's Disease Activity Index (CDAI) value < 150 and a C-reactive protein (CRP) value < 0.5 mg/dL with SB or SB colonic CD. The presence of small-bowel ulcerative lesions (≥0.5 cm) was grouped by SBCE results, and we then compared the groups' LRG value to establish a cutoff value for screening for the presence of lesions. Results: In 40 patients with CD, the LRG values differed significantly between the patients with and without SB ulcerative lesions (Ul + 14.1 (2.1−16.5) µg/mL vs. Ul − 12.3 (9.3−13.5) µg/mL; p = 0.0105). The respective cutoff LRG values for the presence of SB ulcerative lesions was 14 µg/mL (areas under the ROC curve 0.77), with sensitivity 63.6%, specificity 82.8%, positive predictive values 58.3%, negative predictive values 85.7%, and accuracy 78%. Conclusion: These results indicate that LRG may be useful in predicting the presence of SB inflammation associated in patients with CD with CRP < 0.5 mg/dL and CDAI < 150, and in selecting patients for SBCE.

A Novel Capsule Endoscopic Score for Crohn's Disease.

Background and Aims: The Lewis Score (LS) and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) are the two currently used small bowel capsule endoscopy (SBCE) scoring systems for Crohn's disease (CD). The present study describes a new scoring system for evaluation of small bowel CD, especially mucosal inflammation. Methods: In this cross-sectional study, 108 CD patients underwent 196 SBCEs. The small bowel lesions were scored using our new Crohn's Disease Activity in Capsule Endoscopy (CDACE). CDACE is the sum of scores for location of inflammation, range of inflammation, and stenosis, with a value ranging from 0 to 1643. We analyzed the relation between CDACE and LS, CECDAI, CDAI, and CRP values and evaluated the inter-rater reliability of CDACE using the intraclass correlation coefficient (ICC) (2.1). Results: The mean (±SD) values of LS, CECDAI, and CDACE were 501 ± 1177, 5.8 ± 5.4 and 431 ± 356, respectively. CDACE correlated significantly with LS and CECDAI (ρ = 0.737, P < 0.0001 for LS and ρ = 0.915, P < 0.0001 for CECDAI). CDACE also correlated significantly with CDAI (ρ = 0.36) and CRP (ρ = 0.23). The ICC (2.1) was 0.829, indicating strong agreement among readers. Conclusions: CDACE is a potentially useful SBCE scoring system for small bowel CD, as it represents the extent and spread of small bowel mucosal inflammation and stenosis.

Essential role of small bowel capsule endoscopy in reclassification of colonic inflammatory bowel disease type unclassified.

AIM: To evaluate the role of small bowel capsule endoscopy (SBCE) on the reclassification of colonic inflammatory bowel disease type unclassified (IBDU). METHODS: We performed a multicenter, retrospective study including patients with IBDU undergoing SBCE, between 2002 and 2014. SBCE studies were reviewed and the inflammatory activity was evaluated by determining the Lewis score (LS). Inflammatory activity was considered significant and consistent with Crohn's disease (CD) when the LS ≥ 135. The definitive diagnosis during follow-up (minimum 12 mo following SBCE) was based on the combination of clinical, analytical, imaging, endoscopic and histological elements. RESULTS: Thirty-six patients were included, 21 females (58%) with mean age at diagnosis of 33 ± 13 (15-64) years. The mean follow-up time after the SBCE was 52 ± 41 (12-156) mo. The SBCE revealed findings consistent with significant inflammatory activity in the small bowel (LS ≥ 135) in 9 patients (25%); in all of them the diagnosis of CD was confirmed during follow-up. In 27 patients (75%), the SBCE revealed no significant inflammatory activity (LS < 135); among these patients, the diagnosis of Ulcerative Colitis (UC) was established in 16 cases (59.3%), CD in 1 case (3.7%) and 10 patients (37%) maintained a diagnosis of IBDU during follow-up. A LS ≥ 135 at SBCE had a sensitivity = 90%, specificity = 100%, positive predictive value = 100% and negative predictive value = 94% for the diagnosis of CD. CONCLUSION: SBCE proved to be fundamental in the reclassification of patients with IBDU. Absence of significant inflammatory activity in the small intestine allowed exclusion of CD in 94% of cases.

Dissecting Lewis score under the light of fecal calprotectin; an analysis of correlation of score components with calprotectin levels in capsule endoscopy.

BACKGROUND: Lewis Score (LS) is an inflammatory score in small-bowel capsule endoscopy (SBCE). Fecal calprotectin (FC) is considered the non-invasive, 'gold standard' marker of gastrointestinal (GI) inflammation. Recently, we reported that LS shows only a moderate correlation with FC. In this study, we aim to evaluate which LS parameters have greater correlation with FC. METHODS: A retrospective, two-center study; 74 patients who underwent SBCE within 7 (median 1.5) days from a FC measurement. LS was calculated; univariate and multivariate analyses were performed, investigating LS correlation with FC, and which LS parameters had stronger correlation coefficient (rs) with FC. RESULTS: 74 patients had an FC measurement within 7 days of their SBCE examination (median 22 time-interval: 1.5 days; IQR: 5). Coefficient rs between LS and FC was moderate (0.454). In univariate analysis, the variables that gave the strongest association with FC were: the higher tertile subscore for ulcer, the summative ulcer subscore, the higher tertile ulcer score (only with descriptors of ulcer size and number), the summative ulcer score (only with descriptors of ulcer size and number), and subscores including various combinations of the stenosis descriptors. In multivariate analysis, the only positive predictor for FC was the higher tertile ulcer subscore (only with descriptors of ulcer size and number). CONCLUSION: LS shows only moderate correlation to FC. This is due to a) an inherent limitation of LS, and b) the notion of correlating the 2 parameters, and consideration should be given to development of a new, simplified (or composite) inflammation score/index for SBCE.

Lewis Score--Prognostic Value in Patients with Isolated Small Bowel Crohn's Disease.

BACKGROUND AND AIMS: Small bowel capsule endoscopy (SBCE) allows mapping of small bowel inflammation in Crohn's disease (CD). We aimed to assess the prognostic value of the severity of inflammatory lesions, quantified by the Lewis score (LS), in patients with isolated small bowel CD. METHODS: A retrospective study was performed in which 53 patients with isolated small bowel CD were submitted to SBCE at the time of diagnosis. The Lewis score was calculated and patients had at least 12 months of follow-up after diagnosis. As adverse events we defined disease flare requiring systemic corticosteroid therapy, hospitalization and/or surgery during follow-up. We compared the incidence of adverse events in 2 patient subgroups, i.e. those with moderate or severe inflammatory activity (LS ≥790) and those with mild inflammatory activity (135 ≤ LS < 790). RESULTS: The LS was ≥790 in 22 patients (41.5%), while 58.5% presented with LS between 135 and 790. Patients with a higher LS were more frequently smokers (p = 0.01), males (p = 0017) and under immunosuppressive therapy (p = 0.004). In multivariate analysis, moderate to severe disease at SBCE was independently associated with corticosteroid therapy during follow-up, with a relative risk (RR) of 5 (p = 0.011; 95% confidence interval [CI] 1.5-17.8), and for hospitalization, with an RR of 13.7 (p = 0 .028; 95% CI 1.3-141.9). CONCLUSION: In patients with moderate to severe inflammatory activity there were higher prevalences of corticosteroid therapy demand and hospitalization during follow-up. Thus, stratifying the degree of small bowel inflammatory activity with SBCE and LS calculation at the time of diagnosis provided relevant prognostic value in patients with isolated small bowel CD.

Capsule enteroscopy is useful for the therapeutic management of Crohn's disease.

AIM: To analyze therapeutic changes in Crohn's disease (CD) patients following video capsule endoscopy (VCE) and to assess the usefulness of Lewis score and the Patency Capsule. METHODS: Patency Capsule was performed in every patient that had indication for VCE, and those with negative patency did not undergo VCE. Patients with established CD that underwent VCE between January 2011 and February 2014 were selected for this study; those with suspected CD were excluded, independent of VCE results, since our purpose was to address differences in therapeutic regimen in CD patients before and after VCE. Patients with inconclusive VCE were also excluded. Patients had to be free of non-steroidal anti-inflammatories for at least 1 mo. Those patients who met these criteria were allocated into one of three groups: Staging group (asymptomatic CD patients that underwent VCE for staging of CD), Flare group (patients with active CD), or Post-op group (CD patients evaluated for post-operative recurrence). Lewis score was calculated for every VCE procedure. Statistical analysis was performed to address the impact of VCE findings on the therapeutic management of CD patients and to evaluate the utility of the Lewis score. RESULTS: From a total of 542 VCEs, 135 were performed in patients with CD. Patency capsule excluded nearly 25% of the patients who were supposed to undergo VCE. No videocapsule retention during VCE was reported. From these 135 patients, 29 were excluded because CD diagnosis was not established at the time of VCE. Therefore, a total of 106 patients were included in the final analysis. From these, the majority were in the Staging group (n = 73, 69%), and the remaining were in the Flare (n = 23, 22%) or Post-op (n = 10, 9%) group. Median time between diagnosis and VCE was 5.5 years. Overall, VCE determined changes in the treatment of 40% of patients: only 21% remained free of immunosuppressors after VCE compared to 44% before VCE (P < 0.001). The differences in therapy before and after VCE achieved statistical significance in the Staging and Flare groups. In addition, patients were significantly different when stratified regarding time since diagnosis to the date of VCE. A higher Lewis score was associated with therapeutic modifications (P < 0.0001); where a score higher than 1354 was related to 90% probability of changing therapy [area under the receiver operative characteristic (AUROC) 0.80 (95%CI: 0.69-0.88)]. CONCLUSION: VCE significantly changed the therapeutic management of CD patients, even in those with long-term disease. Systematic use of Patency capsule allowed for no videocapsule retention.

Tailoring Crohn's disease treatment: the impact of small bowel capsule endoscopy.

BACKGROUND AND AIMS: Small bowel capsule endoscopy (SBCE) may detect proximal small bowel lesions that have been previously missed by ileocolonoscopy and small bowel imaging in patients with known ileal and/or colonic Crohn's disease (CD). We aimed to evaluate whether the therapeutic management is influenced by SBCE findings. METHODS: Retrospective single center study. Inclusion of consecutive patients with known non-stricturing and non-penetrating ileal and/or colonic CD, submitted to SBCE to evaluate disease extension and activity, with ≥ 1 year follow-up. Lesions were classified with the Lewis score (LS) as non-significant (LS<135), mild (135≤LS≤790), or moderate-to-severe (LS>790). Therapeutic changes were assessed three months after SBCE. RESULTS: Fifty consecutive patients (35±13 years, 52% females) were included. At ileocolonoscopy, disease location was ileal (L1) in 60%, colonic (L2) in 10% and ileocolonic (L3) in 30% of the patients. In 33 patients (66%) SBCE detected significant proximal lesions previously missed by other modalities. The proportion of patients on thiopurines and/or biologics before SBCE was 2/50 (4%); this was significantly higher three months after SBCE, 15/50 (30%), p=0.023. Treatment with thiopurines and/or biologics was started more often in patients with proximal small bowel lesions [13/33 (39%) vs. 1/17 (6%), p=0.011, relative risk (RR) 6.5], particularly when severe (6%, 36% and 45% of patients with non-significant, mild and moderate-to-severe inflammation, respectively). CONCLUSIONS: SBCE diagnoses previously undetected lesions and it influences therapeutic management of CD, triggering an earlier introduction of immunomodulators and/or biological therapy.

Prospective postsurgical capsule endoscopy in patients with Crohn's disease.

AIM: To clarify the usefulness of postsurgical capsule endoscopy (CE) in the diagnosis of recurrent small bowel lesions of Crohn's disease (CD). METHODS: This prospective study included 19 patients who underwent ileocolectomy or partial ileal resection for CD. CE was performed 2-3 wk after surgery to check for the presence/absence and severity of lesions remaining in the small bowel, and for any recurrence at the anastomosed area. CE was repeated 6-8 mo after surgery and the findings were compared with those obtained shortly after surgery. The Lewis score (LS) was used to evaluate any inflammatory changes of the small bowel. RESULTS: One patient was excluded from analysis because of insufficient endoscopy data at the initial CE. The total LS shortly after surgery was 428.3 on average (median, 174; range, 8-4264), and was ≥ 135 (active stage) in 78% (14 of 18) of the patients. When the remaining unresected small bowel was divided into 3 equal portions according to the transition time (proximal, middle, and distal tertiles), the mean LS was 286.6, 83.0, and 146.7, respectively, without any significant difference. Ulcerous lesions in the anastomosed area were observed in 83% of all patients. In 38% of the 13 patients who could undergo CE again after 6-8 mo, the total LS was higher by ≥ 100 than that recorded shortly after surgery, thus indicating a diagnosis of endoscopic progressive recurrence. CONCLUSION: Our pilot study suggests that CE can be used to objectively evaluate the postoperative recurrence of small bowel lesions after surgery for CD.

Blue mode does not offer any benefit over white light when calculating Lewis score in small-bowel capsule endoscopy.

AIM: To check the usefulness of blue mode (BM) review in lewis score (LS) calculation, by comparing it with respective LS results obtained by white light (WL) small-bowel capsule endoscopy (SBCE) review and mucosal inflammation as reflected by faecal calprotectin (FC) levels, considered as 'gold standard' for this study. METHODS: Computational analysis of our SBCE database to identify patients who underwent SBCE with PillCam(®) and had FC measured within a 30-day period from their test. Only patients with prior colonoscopy were included, to exclude any colon pathology-associated FC rise. Each small bowel tertile was reviewed (viewing speed 8 fps) with WL and BM, in a back-to-back mode, by a single experienced reviewer. LS were calculated after each WL and BM reviews. Pearson rank correlation (rho, r) statistic was applied. RESULTS: Twenty-seven (n = 27, 20F/7M) patients were included. Thirteen (n = 13) had SBCE with PillCam(®)SB1, and the remainder (n = 14) with PillCam(®)SB2. The median level of FC in this cohort was 125 µg/g. LS (calculated in WL SBCE review) correlation with FC levels was r = 0.490 (P = 0.01), while for BM review and LS correlation with FC was r = 0.472 (P = 0.013). CONCLUSION: Although BM is believed to enhance mucosal details i.e., small mucosal breaks, it did not perform better than WL in the calculation of LS in our cohort.