Small bowel capsule endoscopy and treat-to-target in Crohn's disease: A systematic review

Abstract

BACKGROUND Crohn’s disease (CD) can affect the entire gastrointestinal tract. Proximal small bowel (SB) lesions are associated with a significant risk of stricturing disease and multiple abdominal surgeries. The assessment of SB in patients with CD is therefore necessary because it may have a significant impact on prognosis with potential therapeutic implications. Because of the weak correlation that exists between symptoms and endoscopic disease activity, the “treat-to-target” paradigm has been developed, and the associated treatment goal is to achieve and maintain deep remission, encompassing both clinical and endoscopic remission. Small bowel capsule endoscopy (SBCE) allows to visualize the mucosal surface of the entire SB. At that time, there is no recommendation regarding the use of SBCE during follow-up. AIM To investigate the impact of SBCE in a treat-to-target strategy in patients with CD. METHODS An electronic literature search was conducted in PubMed and Cochrane library using the following search terms: “capsule endoscopy”, in combination with “Crohn’s disease” and “treat-to-target” or synonyms. Two authors independently reviewed titles and abstracts identified by the search strategy after duplicates were removed. Following the initial screening of abstracts, all articles containing information about SBCE in the context of treat-to-target strategy in patients with CD were included. Full-text articles were retrieved, reference lists were screened manually to identify additional studies. RESULTS Forty-seven articles were included in this review. Two indexes are currently used to quantify disease activity using SBCE, and there is good correlation between them. SBCE was shown to be useful for disease reclassification in patients who are suspected of having or who are diagnosed with CD, with a significant incremental diagnostic yield compared to other diagnostic modalities. Nine studies also demonstrated that the mucosal healing can be evaluated by SBCE to monitor the effect of medical treatment in patients with CD. This review also demonstrated that SBCE can detect post-operative recurrence to a similar extent as ileocolonoscopy, and proximal SB lesions that are beyond the reach of the colonoscope in over half of the patients. CONCLUSION SBCE could be incorporated in the treat-to-target algorithm for patients with CD. Randomized controlled trials are required to confirm its usefulness and reliability in this indication.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn’s disease

“…Postoperative recurrence in proximal small bowel could also be assessed with capsule endoscopy. SBCE is equivalent or superior to conventional endoscopy in the evaluation of the Rutgeerts score to detect CD recurrence [28,29] and has the added advantage of detecting lesions outside the scope of ileocolonoscopy but the drawbacks include requirement of radiologist studies or the use of a patency capsule although this may not be needed early postoperatively or in patients with no obstructive symptoms [30]. Intestinal US and MR enterography have also demonstrated high diagnostic accuracy in detection of endoscopic recurrence after surgery [31].…”

Wireless Capsule Endoscopy for Diagnosis and Management of Post-Operative Recurrence of Crohn’s Disease

“…In addition, it is believed that EPOR only occurs at the neo-terminal ileum after surgery [ 12 ]. However, the presence of additional small bowel lesions after surgery would question such a principle and potentially impact therapeutic interventions [ 39 ]. Currently, WCE in post-operative CD patients is recommend by some authors only in the presence of unexplained clinical symptoms or biochemical marker elevations [ 40 ].…”

The role of small-bowel endoscopy in inflammatory bowel disease: an updated review on the state-of-the-art in 2021

“…The ECCO-ESGAR guidelines suggest that FC, SICUS, MRE and SBCE can all be considered as noninvasive alternatives to detect postoperative recurrence [ 13 ]. A recent systematic review demonstrated that SBCE can detect postoperative recurrence to a similar extent as IC, and proximal SB lesions that are beyond the reach of a colonoscope in over 50% of patients [ 95 ]. PC use should always be considered before SBCE in this setting in order to rule out any postoperative stricturing, thus mitigating the risk of potential capsule retention.…”