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Endoscopic assessment of the small bowel is difficult because of its long and tortuous anatomy. However, recent developments have greatly improved the insertion depth and diagnostic yield, by means of device-assisted enteroscopy (DAE). Therefore, DAE may be of specific interest in the diagnostic and therapeutic approach of patients with inflammator...
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Crohn disease (CD) may be complicated by contiguous, metastatic, or associated inflammatory cutaneous lesions. Vulvar CD is a rare phenomenon characterized by granulomatous genital inflammation that occurs independently from fistulizing CD. Left untreated, vulvar CD can result in debilitating lymphedema, disfiguring anatomic changes, secondary absc...
Citations
... Short diaphragm-like strictures were typical of NSAIDs injury, whereas eccentric longer segment involvement was commonly seen in Crohn's disease. 53 In a review of SBE findings in Crohn's disease, other than the typical longitudinal ulceration at the mesenteric border, there were findings of cobble stoning, fistulae (usually proximal to stricture), and pseudodiverticulae; none of which have been described in NSAID injury. In addition, adenocarcinoma or lymphoma may complicate Crohn's disease. ...
Nonsteroidal anti-inflammatory drug (NSAID)-induced enteropathy is an increasingly recognized entity. Patients of older age and those suffering from conditions such as arthritis requiring long term NSAIDs are thought to be at greater risk. Introduction of enteroscopic techniques has greatly improved understanding of NSAID-related small intestinal injury. Complementary high-resolution cross-sectional imaging techniques aid in initial evaluation and for exclusion of alternative etiology. Erosions, superficial ulcerations, and short segment strictures are the most commonly described findings. The diagnosis of the condition lies in obtaining relevant history in addition to a high degree of suspicion during investigation of anemia, obscure gastrointestinal bleeding, small bowel obstruction, and protein losing enteropathy. Herein, the authors present a review of pathogenesis and imaging findings of NSAID enteropathy with particular emphasis on distinction from Crohn’s enteropathy.
... DBE is often used following WCE due to potential miss rate of the latter and to guide the approach of insertion of DBE (antegrade or retrograde). The standard system has an endoscope with an outer diameter of 8.5 mm and a working length of 200 cm [38][39][40] . It is also provided with a 145 cm soft overtube with 12.2 mm outer diameter and a dedicated pump. ...
... Either air or carbon dioxide can be used, the latter recommended due to better patient tolerance, especially for therapeutic procedures and less post procedural discomfort, when a prolonged procedure is anticipated. Fluoroscopic guidance could be used till competence is achieved, but is not essential [39][40][41]43] . The overall yield of DBE was better than push enteroscopy and similar to capsule. ...
... The overtube can be disengaged from the coupler enabling complete withdrawal of the endoscope and reintroduction (often needed for removal of multiple polyps), without losing the position in the small bowel [42,71,[84][85][86] . The other major advantage is that no dedicated enteroscopy system needs to be purchased and the Endo-Ease spiral overtube could transform an ordinary enteroscope or a paediatric colono-scope to a SE device [40,77,78,81] . Spiral enteroscopy is very useful for proximal small bowel pathology, especially for therapeutic interventions, due to the stability achieved with the overtube. ...
Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in inflammation, stricturing and fistulae secondary to transmural inflammation. Diagnosis relies on clinical history, abnormal laboratory parameters, characteristic radiologic and endoscopic changes within the gastrointestinal tract and most importantly a supportive histology. The article is intended mainly for the general gastroenterologist and for other interested physicians. Management of small bowel CD has been suboptimal and limited due to the inaccessibility of the small bowel. Enteroscopy has had a significant renaissance recently, thereby extending the reach of the endoscopist, aiding diagnosis and enabling therapeutic interventions in the small bowel. Radiologic imaging is used as the first line modality to visualise the small bowel. If the clinical suspicion is high, wireless capsule endoscopy (WCE) is used to rule out superficial and early disease, despite the above investigations being normal. This is followed by push enteroscopy or device assisted enteroscopy (DAE) as is appropriate. This approach has been found to be the most cost effective and least invasive. DAE includes balloon-assisted enteroscopy, [double balloon enteroscopy (DBE), single balloon enteroscopy (SBE) and more recently spiral enteroscopy (SE)]. This review is not going to cover the various other indications of enteroscopy, radiological small bowel investigations nor WCE and limited only to enteroscopy in small bowel Crohn's. These excluded topics already have comprehensive reviews. Evidence available from randomized controlled trials comparing the various modalities is limited and at best regarded as Grade C or D (based on expert opinion). The evidence suggests that all three DAE modalities have comparable insertion depths, diagnostic and therapeutic efficacies and complication rates, though most favour DBE due to higher rates of total enteroscopy. SE is quicker than DBE, but lower complete enteroscopy rates. SBE has quicker procedural times and is evolving but the least available DAE today. Larger prospective randomised controlled trial's in the future could help us understand some unanswered areas including the role of BAE in small bowel screening and comparative studies between the main types of enteroscopy in small bowel CD.
Background and aim
Fecal calprotectin (FC) is a useful marker for assessing the activity of intestinal inflammation. However, most studies have used ileocolonoscopy to evaluate the association of FC with intestinal inflammation and it is not clear whether FC is useful for the evaluation of small bowel Crohn's disease (CD). This study aimed to determine the usefulness of FC for predicting intestinal inflammation evaluated by balloon‐assisted endoscopy (BAE), which can visualize the deep small intestine.
Methods
This was a cross‐sectional, observational study involving 69 CD patients, 39 of whom had only small bowel disease. The extended simplified endoscopic activity score for Crohn's disease (eSES‐CD) was calculated based on the findings of BAE. Mucosal healing was defined as an eSES‐CD of 0.
Results
In all CD patients, FC levels were correlated with the eSES‐CD (r=0.663, p<0.001). The cut‐off value to predict mucosal healing was 92 mg/kg, with a sensitivity of 94%, specificity of 88%, positive predictive value (PPV) of 98%, negative predictive value (NPV) of 64%, and the area under the curve (AUC) of 0.91. Even in small bowel CD patients, FC levels were correlated with the eSES‐CD (r=0.607, p<0.001). The cut‐off value was 92mg/kg, with a sensitivity of 87%, specificity of 88%, PPV of 96%, NPV of 64%, and AUC of 0.85.
Conclusions
FC showed a significant correlation with the intestinal inflammation evaluated with BAE even in patients with only small intestinal disease. FC is useful for the evaluation of CD including both the small and large intestine.
Background & aims:
Previous studies have not found a correlation between fecal level of calprotectin and small bowel Crohn's disease (CD). However, these studies evaluated patients mainly by ileocolonoscopy, which views up to only the terminal ileum rather than entire small intestine. We investigated whether level of fecal calprotectin (FC) is a marker of active CD of the small bowel, identified by balloon-assisted enteroscopy and computed tomography enterography (CTE).
Methods:
We performed a prospective study of 123 patients with CD (35 with ileitis, 72 with ileocolitis, and 16 with colitis) evaluated by balloon-assisted enteroscopy from May 2012 through July 2015 at Toho University Sakura Medical Centre in Japan. Patients with strictures detected by balloon-assisted enteroscopy were evaluated by CTE (n = 17). Fecal samples were collected from each patient, and levels of calprotectin were measured; patient demographic variables and medical history were also collected. We developed a CTE scoring system for disease severity that was based on bowel wall thickness, mural hyperenhancement, and engorged vasa recta. The association between level of FC and simple endoscopic index for CD score or CTE was evaluated by using Spearman rank correlation coefficient.
Results:
Level of FC correlated with the simple endoscopic index for CD score (r = 0.6362, P < .0001), even in patients with only active disease of the small intestine (r = 0.6594, P = .0005). In the 17 patients with strictures that could not be passed with the enteroscope, CTE detected all lesions beyond the strictures as well as areas in the distal side of the strictures. Level of FC correlated with CTE score in these patients (r = 0.4018, P = .0011, n = 63). In receiver operating characteristic analyses, the FC cutoff value for mucosal healing was 215 μg/g; this cutoff value identified patients with healing with 82.8% sensitivity, 71.4% specificity, positive predictive value of 74.3%, negative predictive value of 80.6%, odds ratio of 12.0, and area under the receiver operating characteristic curve value of 0.81.
Conclusions:
A combination of measurement of level of FC and CTE appears to be effective for monitoring CD activity in patients with small intestinal CD, including patients with strictures that cannot be passed by conventional endoscopy.
