DIAGNOSTIC APPROACH TO SMALL BOWEL

INVOLVEMENT IN IBD: VIEW OF THE ENDOSCOPIST

Konstantinos A. Papadakis, MD, PhDUniversity of Crete, Faculty of

Medicine, University Hospital of Heraklion, Crete, Greece

5%Gastroduodenitis

5%Gastroduodenitis

40%Ileocolitis

30%Ileitis/

Jejunoileitis

25%Colitis

CrohnCrohn’’s Diseases DiseaseAnatomic DistributionAnatomic Distribution

How do we approach SB involvement in IBD?

• Barium radiography has been the conventional test for diagnosis of small-bowel Crohn’s disease

• Ileocolonoscopy is necessary to assess for colonic and terminal ileal mucosa, and to obtain biopsy specimens.

Crohn, Ginzburg and Oppenheimer JAMA 1932

• Push Enteroscopy• Sonde Enteroscopy• Intra-operative Enteroscopy• Wireless capsule endoscopy• Double-Balloon Enteroscopy• Single-Balloon Enteroscopy

Older and Newer Techniques for SB Evaluation

Limitations of Diagnostic Techniques in Evaluating SB CD

• Gold standard in diagnosing Crohn’s disease

• Sensitivity, specificity and diagnostic accuracy

• Safety issues, cost-effectiveness• Incorporate into patient management• What impact does it have in long-term

management of CD

The Capsule

• Diameter 11mm: Length 26mm• Optical dome: Intestinal illumination

by white light emitting diodes (LED’s)

• Lens• Complementary metal-oxide

silicone imager (color camera chip)• Transmitter• Two batteries (silver oxide)

The Capsule

Potential indications for the use of wireless capsule endoscopy in patients with Inflammatory Bowel Diseases (IBD).

• a) Suspected CD (i.e abdominal pain, diarrhoea, elevated CRP) with negative findings on upper gastrointestinal (GI) endoscopy and colonoscopy

• b) Evaluation of obscure (gastroscopy- and colonoscopy-negative) GI bleeding in patients with CD

• c) Evaluation of disease extent in patients with CD∗• d) Evaluation of post-operative recurrence∗∗• e) Evaluation of patients with indeterminate colitis• f) Evaluation of response to anti-inflammatory therapy if

indicated (i.e. in patients with persistent symptoms despite appropriate therapy).

• ∗ If information of disease extent in the SB is likely to change patient management.

• ∗∗ Mainly in patients unwilling to undergo ileocololonoscopySaruta and Papadakis. Expert Rev. Mol. Diagn. 2009

Contraindications to wireless capsule endoscopy

• Clinical or radiographic evidence of bowel obstruction or pseudo-obstruction

• Severe and extensive small bowel CD with or without stricture or fistula

• Patients with cardiac pacemakers or other implanted electromedical devices

• Patients with swallowing disorders • Extensive small intestinal diverticulosis (rare)

• Warnings to performing WCE • 1) Previous abdominal or pelvic surgery• 2) Pregnancy• 3) Young children (below 10 years)

Saruta and Papadakis. Expert Rev. Mol. Diagn. 2009

Capsule Endoscopy in CrohnCapsule Endoscopy in Crohn’’s Diseases Disease

• Can detect erosions/ulcersin suspected Crohn’s with negative SBFT or enteroclysis

• Highly sensitive but lessspecific

• Use cautiously in known Crohn's (capsule retention ranges from 0 to 13%)

Kornbluth A, et al. Endoscopy. 2005;37:1051-4Fireman Z, et al. Gut 2003; 52:390-2.

Spectrum of Crohn’s Lesions

Spectrum of Crohn’s Lesions

Proximal Jejunal Crohn’s Ulcer

Ulcer on capsule

Ulcer on endoscopy

Granuloma on histology

How does SBCE compare to small bowel radiology?

Costamagna 2002Dubcenco 2004Eliakim 2004Toth 2004Chong 2005Hara 2005

0.00 [-0.85, 0.85]0.38 [-0.04, 0.79]0.54 [0.35, 0.74]0.17 [-0.02, 0.37]0.00 [-0.11, 0.11]0.24 [-0.16, 0.66]0.24 [-0.03, 0.51] 43 versus 13 %Total yield

Diagnostic yield SBCE versus SBFT (suspected CD patients)

Eliakim 2004Hara 2005

0.57 [-0.38, 0.76]0.13 [-0.33, 0.58]

0.40 [-0.03, 0.83] 70 versus 21 %Total yield

Diagnostic yield SBCE versus CT/enteroclysis (suspected CD patients)

Triester SL et al. Am J Gastroenterol 2006;101:954.

Sensitivity (%) Specificity (%)

SBCE 83 53

Ileocolonoscopy 67 100

CT / Enteroclysis 67 100

SBFT 50 100

Sensitivity (%) Specificity (%) P

SBCE + ileocolonoscopy 100 57

CT/E + ileocolonoscopy 84 94 0.03

SBFT + ileocolonoscopy 78 100 0.03

SBCE + CT/E 92 53 NS

Solem et al. Gastrointest Endosc 2008;68:255-66.

SBCE has high sensitivity but low specificity

Position statements

Ileocolonoscopy must be performed prior to SBCE for the diagnosis of Crohn’s disease [EL4, RG C]

Small bowel cross sectional imaging should generally precede SBCE

The choice of radiographic imaging depends on local availability and expertise [EL5, RG D]

There is no available evidence to support a particular bowel preparation for SBCE [EL5 RG D]

SBCE detects small lesions not seen by radiographic techniques

But what is their significance ?

Diagnostic criteria used in suspected CDPatients

(suspected CD)Comparator Diagnostic Criteria

(SBCE) Findings

Costamagna et al 2002 20 (1) SBFT Medically significantMedically significant Ulcers Ulcers

Eliakim et al 2004 25 (25) SBFT / CT Medically significantMedically significant

Ulcers, erosions, erythema, Ulcers, erosions, erythema, aphtae, nodular lymphoid aphtae, nodular lymphoid

hyperplasiahyperplasiaDubcenco et al 2005 44 (11) SBFT >> 3 ulcerations3 ulcerations

Erythema, edema, loss of Erythema, edema, loss of villi, stricture, mucosal villi, stricture, mucosal fissure, fistula, scarringfissure, fistula, scarring

Chong et al 2005 43 (21) SBFT / PE Medically significantMedically significant Erosions, ulcersErosions, ulcers

Hara et al 2006 17 (8) SBFT / CT Consistent with CDConsistent with CD Erosion, ulcer, strictureErosion, ulcer, stricture

Gölder et al 2006 36 (2) MR / E > 1 aphtoid ulcer > 1 aphtoid ulcer Not describedNot described

Solem et al 2008 41 (?) SBFT / CT Consistent with CDConsistent with CD Unknown Unknown

Development of a capsule endoscopy scoring index forsmall bowel mucosal inflammatory change

Gralnek IM, et al. Aliment Pharmacol Ther 2008

SBCE has a high diagnostic yield in established CD

Costamagna 2002Dubcenco 2004Marmo 2004Toth 2004Chong 2005Hara 2005

0.50 [-0.21, 1.21]0.70 [0.49, 0.90]0.45 [0.23, 0.67]0.61 [0.35, 0.87]0.62 [0.38, 0.86]0.67 [0.34, 0.99]0.51 [0.31, 0.70] 78 versus 32 %Total yield

Diagnostic yield SBCE versus SBFT (established CD patients)

Voderholzer 2005Hara 2005

0.32 [0.11, 0.52]0.22 [-0.08, 0.52]

0.30 [0.12, 0.48] 68 versus 38 %Total yield

Diagnostic yield SBCE versus CT/enteroclysis (established CD patients)

Triester SL et al. Am J Gastroenterol 2006;101:954.

2 / 2214 / 54ND6 / 532 / 45ND

15 / 56ND

Patients excluded after radiologic findings (17 %)

In the terminal ileum, SBCE is no more useful than CT / enteroclysis

0

5

10

15

20

25

30

35

40

Small intestine terminal ileum

SBCECT / E

Number of patients with lesions

Voderholzer WA et al. Gut 2005;54:369.

P = 0.004 NS

Position statements

The role of SBCE in patients with established CD should focus on patients with unexplained symptoms when other investigations are inconclusive, if this will alter management[EL 5, RG D]

Radiographic imaging takes precedence over SBCE because it can potentially identify obstructive strictures, extraluminal disease, the transmural nature, or the anatomical distribution of disease

SBCE in patients with established CD

• 134 symptomatic patients with established CD (Abdominal pain, Diarrhea, GIB/Fe deficiency anemia or combination)

• ~50% of pts findings c/w active CD• Distribution of SB lesions: 32% duodenum, 53%

jejunum, 67% proximal ileum and 85% distal ileum• CE comparable to ileoscopy in detecting ileal

ulcerations (55% vs. 48%)• CE vs. SBFT: incremental yield 32% with 95% CI

9% to 54% (p=0.0017).

Mehdizadeh S, et al., (submitted)

Recurrence defined by a Rutgeerts’ score > i232 patients included; 14 recurrences (45 %).SBCE interpreted by two independent observers.

Ileocolonoscopy SBCE

SBCE +/- FN SBCE +/- RP

Sensitivity 86 50 79

Specificity 100 100 94

SBCE and post-operative recurrence

Bourreille et al. Gut 2006;55:978.

Rutgeerts score assessed at WCE

Rutgeerts score assessed at colonoscopy

0

1

2

3

0 1 2 3

R = 0,64P < 0.05

Correlation of Rutgeerts score between SBCE and ileocolonoscopy

Bourreille et al. Gut 2006;55:978.

10 patients

3 patients

2 patients

1 patient

Position statements

For assessment of post-operative recurrence of CD, SBCE should only be considered if ileocolonoscopy is contraindicated or unsuccessful.

SBCE may identify lesions in the small bowel that have not been detected by ileocolonoscopy after ileocolonic resection

Capsule Endoscopy in UC and IBDU

Mehdizadeh S, et al. Endoscopy 2008

Double Balloon Endoscopy System

Single-Balloon Enteroscopy

• 78 procedures were performed in 41 patients

• Suspected mid-gastrointestinal bleeding (n = 12), Crohn’s disease (n = 17), abdominal pain (n = 8), and abdominal tumor(n = 4).

• 6/24 patients complete SB exploration

Tsujikawa T et al., Endoscopy 2008

Therapeutic enteroscopic interventions using BAE: current indications and complication rates

Aktas and Mensink. Dig Dis 2008

• Characteristics of stenosis– short (< 2 cm)– Fibrotic– 1-3 Stenoses– In case of inflammation: treat medically, on

follow-up perform dilation if necessary• Follow-up: clinical, laboratory, ultrasound of the small

bowel (Power-Doppler) or small bowel MRT

Important: always use fluoroscopy and a guidewire(e.g. Jagwire) (guidewire assited balloon dilation)

Criteria for endoscopic dilation

Rejchrt S. et al. Tech GI Endosc 2008

Small bowel stenosis in Crohn‘s disease: balloon dilation with DBE

PROs CONsWCE -Allows the complete

evaluation of thesmall bowel

-Unfeasible if significantstricture present

-High diagnostic yield -Lower specificity of WCE findings

-Useful inindeterminate colitis

-Unable to obtain tissue

-Well tolerated -Inability for therapeutic intervention

Double-Balloon -Allows the completeevaluation of thesmall bowel

-Invasive procedurerequiring sedation andFluoroscopy

-Therapy and biopsiesare feasible

-Limited data in CD

Pros and cons of WCE and Bouble-Balloon Enteroscopy inthe study of the SB in CD

Saibeni S, et al. World J Gastroenterol 2007

Thank you!