Expansive View of Endoscopy from Porto IBD Group

The pediatric IBD Porto Group of ESPGHAN has updated endoscopy guidelines: S Oliva et al. JPGN 2018; 67: 414-430.   In total, the authors make 17 recommendations –here are a few of them:

A) In non-emergency situations, the diagnostic evaluation for suspected IBD in children should include a combination of EGD and colonoscopy.  Multiple biopsies from each segment are recommended even in the absence of macroscopic disease.

B) Endoscopic evaluation is recommended for the following:

  • before major treatment changes
  • in symptomatic patients when it is not clear whether the symptoms are inflammation-related
  • in Crohn’s disease(CD) to ensure mucosal healing during clinical remission
  • in Ulcerative colitis (UC) to ensure mucosal healing during clinical remission only if fecal calprotectin is elevated

C) 6-12 months after bowel resection to identify postoperative recurrence

D) Endoscopic surveillance in pediatric UC after 10 years from the onset of disease (as early as 8 years in older children (>16 years) with risk factors like extensive disease and strong family history

E) In patients with concurrent primary sclerosing cholangitis (PSC), surveillance colonoscopy may be considered every 1-2 years, starting from time of PSC diagnosis. However, in children <12 years of age, surveillance could be postponed based on individual risk factors.

In addition to discussions of conventional endoscopy, the authors favor evaluation of small bowel inflammation: “the choice to perform CE [capsule endoscopy], MRE or both, depends on local availability and expertise.”  The authors caution to consider strictures and the potential need for patency capsule prior to CE.

Conclusion of authors: “Endoscopy in pediatric IBD provides a more definitive diagnosis and disease extent evaluation, assesses therapeutic efficacy and leads to targeted therapy, which lessens complications and progression.”

My take: While I agree that endoscopy increases our understanding of disease extent and response to treatment, I do have some concerns about the recommendations (under section B above) regarding assessment of mucosal healing.  Part of the concern is that there is not a single accepted definition of mucosal healing.  Also, as a practical matter, there needs to be a discussion of the costs and more proof that frequent endoscopy will improve outcomes; it is possible that increased use of endoscopy will lead to some detrimental outcomes in some patients based on the interpretation of the results (eg. dropping a therapy that may be helping and replacing with a less effective treatment)..

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Capsule Endoscopy More Sensitive than MRE for Crohn’s Disease

Briefly noted: B Gonzalez-Suarez et al. IBD 24: 775-80.

In 47 patients with established (n=32) or suspected Crohn’s disease (n=15), MRE was first performed to exclude strictures and then subsequently capsule endoscopy (CE) (with patency capsule in 10 patients). Key finding: Small bowel lesions were found in 36 of 47 with CE compared with 21 of 47 with MRE (76.6% vs 44.7%, P=0.001)

Related blog post: Head-to-Head: Capsule endoscopy compared to colonoscopy

Magnetically Controlled Capsule Endoscopy

I’m not sure this will take off, but a recent study (Z Liao et al. Clin Gastroenterol Hepatol 2016; 14: 1266-73) showed the feasibility and accuracy of using a magnetically controlled capsule endoscopy (MCE) to detect diseases in the stomach with a high rate of accuracy.

This was a multicenter blinded study comparing MCE with conventional gastroscopy in 350 patients (mean age 46.6 years).  Technique: MCE system relied on a guidance robot with a C-arm.  The capsule could also be manipulated manually with a joystick.  Examinations took no longer than 30 minutes and required no sedation.  To improve visualization, a defoaming agent and pronase granules (to remove mucus) were given.  Also, if visualization was not adequate, the patient was instructed to infest water.

Key findings:

  • MCE detected lesions in the stomach with 90.4% sensitivity and 94.7% specificity.  The negative predictive values was 95.9%.
  • 110 (31.4%) patients who had MCE required endoscopic biopsies.

In patients capable of swallowing the capsule, MCE could allow very good inspection of the stomach without sedation and at much lower cost.  In adults, nearly a third would still need conventional gastroscopy to obtain biopsies and MCE would not be ideal for detecting duodenal diseases like celiac disease.

My take: I doubt MCE will be used much in this country anytime soon.

this is art?

this is art?

Identifying Anastomotic Ulcers with Capsule Endoscopy

A retrospective review (LM Bass et al. JPGN 2015; 61: 215-9) showed that capsule endoscopy (CE) can be helpful in identifying anastomotic ulcers among patients with short bowel syndrome and chronic GI blood loss.

This study of 4 patients (& 6 CE procedures) indicated that two of these patients underwent surgery after identifying anastomotic ulcers.  The other common treatment was antibiotics. In the suggested evaluation CE was used after upper/lower endoscopy. The recommended role for patency capsule/small bowel imaging is not clearly spelled out, but should be carefully considered due to the risk of strictures.

“The decision to perform CE is made in conjunction with medical and surgical teams so that, although every effort is made to avoid a situation that may result in a retained capsule, both parents and care teams are prepared.”

Related blog posts:

Specific Carbohydrate Diet in Children -Ahead of Print

Here is a link, bit.ly/1xb1kk8, (from JPGN) and the abstract to an article on the Specific Carbohydrate Diet in Children.  This study shows clinical improvement and mucosal healing, confirmed by capsule endoscopy, in response to the specific carbohydrate diet (SCN). Congratulations to my colleagues/partners from GI Care for Kids who published this study in JPGN:

Objective: To prospectively evaluate clinical and mucosal responses to the specific carbohydrate diet (SCD) in children with Crohn’s disease (CD).

Methods: Eligible patients with active CD (Pediatric Crohn’s Disease Activity Index, PCDAI >= 15) underwent a patency capsule and if passed intact, capsule endoscopy (CE) was performed. Patients were monitored on SCD for 52 weeks while maintaining all prescribed medications. Demographic, dietary and clinical information, PCDAI, Harvey Bradshaw (HB) and Lewis score (LS) were collected at 0, 12 and 52 weeks. CE’s were evaluated by an experienced reader blinded to patient clinical information and timing.

Results: Sixteen patients were screened; 10 enrolled; and 9 completed the initial 12 week trial; receiving 85 % of estimated caloric needs prior to, and 101%, on the SCD. HB significantly decreased from 3.3 + 2.0 to 0.6 + 1.3 (p = 0.007) as did PCDAI (21.1 + 5.9 to 7.8 + 7.1; p = 0.011). LS declined significantly from 2153 + 732 to 960 + 433 (p = 0.012). Seven patients continued the SCD to 52 weeks with HB (0.1 + 0.4) and PCDAI (5.4 + 5.5) remaining improved (p = 0.016 and 0.027 compared to baseline) with mean LS at 1046 + 372 and 2 patients showing sustained mucosal healing.

Impressions: Clinical and mucosal improvements were seen in children with CD using the SCD over 12 and 52 weeks. Additionally, CE can monitor mucosal improvement in treatment trials for pediatric CD. Further studies are critically needed to understand the mechanisms underlying SCD’s effectiveness in children with CD.

Related Blog Posts:

Pediatric capsule endoscopy experience

Capsule endoscopy (CE) in pediatric gastroenterology has become a routine procedure.   The experience of our group is noted in a recent study (JPGN 2012; 54: 409-13).  In this study, our single pediatric center reviewed 284 CE procedures (277 patients) over a five-year period.  The youngest patient to swallow a capsule was 4.6 years old.  Twenty capsules were placed endoscopically, with the youngest & smallest patient being 3 years old (13.5kg).  A patency capsule was used in 23 patients.

Overall, the yield with CE was high. 205 (72%) had positive findings; 154 (54%) had small bowel findings.  The study also compared its data to pediatric and adult meta-analysis.  Similar to other pediatric studies, Crohn disease was the most common indication; in adult studies, CE is used mostly for occult GI bleeding and anemia.  CE procedures did not reach the colon in 65 (21%); 36 of these incomplete procedures had positive findings.

Capsule retention occurred in seven patients (2.4%) which is similar to the meta-analysis studies as well.  Six of the seven had surgery due to capsule retention, though one surgical procedure had been planned and capsule helped identify stricture site.  In addition, one of the seven was retrieved through a tight ileostomy.

Additional references:

  • -Gastroenteology 2010; 139: 1468. Predictions for upcoming advances.
  • -Gastroenterology 2009; 137: 1197. Strongest indication -obscure bleeding.
  • -JPGN 2009; 49: 196. Capsule retention in 5.2% in known IBD. overall 3 of 207 studies (1.4%) To date, >170,000 capsule studies worldwide.
  • -Gastrointest Endosc 2008; 68: 255-66. Authors recommend using CT/colonoscopy as primary investigations & reserving capsule only if negative initial evaluation. 17% of pts had asymptomatic partial small bowel obstruction -contraindicating use of capsule.
  • -Endoscopy 2008; 40: 30-35 & -IBD 2008; 14: 1287. Consider wireless capsule before IPAA in UC.
  • -IBD 2008; 14: 1219. Correlation of capsule & MRI enterolysis. Capsule detected more mucosal lesions.
  • -JPGN 2008; 47: 31. Capsule endoscopy may reclassify pediatric IBD
  • Speed matters.  Additional references listed on this previous blog entry.