Jonathan A. Leighton, MD

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Small Bowel Evaluation Choosing the Best
Radiologic and Endoscopic Modalities

• Jonathan A. Leighton, MD
• Mayo Clinic Arizona
• leighton.jonathan_at_mayo.edu
• Great Debates and Updates in IBD
• San Francisco, CA March 2013

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Importance of Small Bowel Evaluationin Crohns
Disease

• The diagnosis of SB inflammation can be
  challenging when inflammation is mild and/or
  confined to the small bowel
• A comprehensive evaluation of the entire small
  bowel may be indicated to
• Make a definitive diagnosis of CD
• Determine extent and severity of disease
• Determine baseline disease activity to serve as a
  comparator for monitoring of disease
• Imaging Techniques
• Capsule Endoscopy
• CT/MR Enterography
• Deep Enteroscoppy

CD Crohns disease CI colonoscopy with
ileoscopy.
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Why Might Capsule Endoscopy (CE) Be Helpful?

• Isolated involvement of the proximal SB can occur
  in as many as one third of cases
• Normal findings on ileocolonoscopy are not
  sufficient to exclude the diagnosis
• Cross-sectional imaging can detect transmural
  inflammation but superficial mucosal inflammation
  may be missed
• CE offers a comprehensive evaluation of the SB
  mucosa to identify CD missed by conventional
  endoscopy and/or evaluate extent and severity of
  involvement
• Debate still exists as to its role in the
  diagnosis and management of Suspected and
  Established Crohns disease

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Case Study

• 42 yo male with history of ileal Crohn disease
  diagnosed in 2001 in Chicago treated with 5ASA
• Recurrent episodes of abdominal pain and SBO with
  otherwise negative CT scans
• Presented to Mayo Clinic March 2012 with
  abdominal pain and black stools
• EGD negative

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Negative Colonoscopy and Ileoscopy
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Negative MR Enterography
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Positive CE
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Endoscopic Skipping of the Distal Terminal Ileum

• 189 consecutive patients with CD
• 153 TI intubation
• 67 had normal ileoscopy
• 67 patients with normal ileoscopy
• 36 had active small bowel CD
• Skipped distal ileum in 11
• Intramural/mesentery disease only in 23
• Upper GI tract in 2

Samuel S et al. CGH 2012101253-59
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A Prospective Multicenter Blinded Study Comparing
CE vs SBFT Before Ileocolonoscopy (IC) in
Suspected Crohn Disease

• Aim compare diagnostic yield of CE before IC vs
  SBFT and IC.
• Results 80 patients were included in the
  analyses.
• Diagnostic yield of CE IC (P.09).
• Diagnostic yield CE gt SBFT (Plt.001).
• 25 (31.3) had the diagnosis of CD confirmed.
• 11 diagnosed by CE alone/5 diagnosed by IC alone
• 9 were identified by at least 2 of the 3
  modalities.
• Conclusion
• IC remains the diagnostic test of choice
• CE was clearly better than SBFT for SB
  inflammation and CD
• CE demonstrated equivalency to IC for ileocecal
  inflammation.
• This study suggests that CE is safe and can
  diagnosis CD when IC is negative.

Leighton JA et al. Submitted for publication
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CE and Suspected Crohns DiseaseFinal Thoughts

• Although CE has greater sensitivity for mucosal
  inflammation than radiology, the PPV is fair at
  50
• False positives and an increased risk of
  retention may limit the widespread use
• The NPV at 96 suggests that CE may be better for
  excluding Crohns disease than confirming it
• CE may play an even more important role in
  established CD

Tukey M et al. Am J Gastro 20091042734-9 Levesqu
e BG, et al. Clin Gastro Hep 2010261-7 Goldfarb
NI et al Dis Manag 7292-304, 2004
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CE for Established IBD

• In the majority of cases, may be a better tool
  for monitoring disease extent and severity
• Using a standardized scoring system may aid in
  objectively tracking disease activity
• Potential Applications
• Postoperative recurrences
• Indeterminate colitis
• Mucosal healing

Doherty GA et al. GIE 201174167-75
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Impact of CE on Management of Known IBD

• 128 CE performed for symptomatic IBD (86 for
  Crohn's disease, 15 for indeterminate colitis, 23
  for pouchitis.
• Results
• In CD, 61.6 had a change in meds in the 3 months
  after CE, with 39.5 initiating a new IBD
  medication
• Severe findings resulted in significant
  differences in
• Med changes (73.2 versus 51.1, P 0.04),
• Addition of meds (58.5 versus 22.2, P lt 0.01)
• Surgeries (21.9 versus 4.4, P 0.01).
• CE results in management changes in the majority
  of cases of symptomatic IBD, regardless of the
  subtype of IBD

Long MD et al. IBD 2011171855- 62
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CE in Patients with Perianal Disease

• 26 patients with perianal disease but negative
  endoscopic evaluation (ileocolonoscopy, SBFT,
  CTE/MRE)
• Results
• 25 underwent CE
• 6/25 (24) identified SB inflammation consistent
  with CD
• No other variables (lab) were predictive

Adler, SN et al. WJGE 20124185-188
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Bottom Line

• CE has a high diagnostic yield for evaluating
  abnormalities of the SB mucosa
• Specificity is an issue and NSAIDs should be
  stopped before CE it is critical not to
  prematurely diagnose CD
• CE for suspected CD may be best suited for a
  subgroup of patients with negative
  ileocolonoscopy and a high suspicion of small
  bowel inflammation
• CE may also be suited for established CD for
  monitoring extent and severity, mucosal healing,
  postop recurrence, and indeterminate colitis
  although cost effectiveness needs to be
  established

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CT Enterography (CTE)

• Oral contrast Neutral
• Rate 450 cc every 15 min
• Amt 1350 cc over 45 min

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Low Dose CT 30-50 less radiation
Filtered back projection Increased noise
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CTEDifferentiating Active vs Chronic CD
N 96 pts with CTE and endoscopy
CTE Finding Sens () Mural hyperenhancement 80 Bow
el wall thickening 75 Mural stratification 60 Comb
sign 35 Inc. mesenteric fat atten 10
Bodily K et al Radiology 2006238505-516
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Small BowelNormal vs Crohns Disease
Enhancement Homogeneous Distended Bowel Wall
Thickness lt3 mm
Enhancement Increased Bowel Wall Thicknessgt3mm
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CTE in Suspected CD with Negative Ileoscopy

• Retrospective study of 189 patients with CD TI
  intubation in 153
• 67 had normal ileoscopy
• 36 were found to have active SB CD
• Two had gastroduodenal CD
• CTE was positive in 34 patients with more
  proximal disease (11) or intramural disease (23)

Samuel S et al. Clin Gastro Hep 2012101253-59
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Using CTE To Monitor CD Activity

• Retrospective study of 20 pts with CD who
  underwent 40 CTE evaluated while blinded to
  clinical history
• Results
• Disease progression or regression by CTE
  correlated with symptoms in 16/20 (80) pts
• In 4/20 (20) pts, symptoms progressed while CTE
  findings were negative (n2) or improved (n2)
• Endoscopy correlated with CTE findings in 12/12
  and with symptoms in 9/12
• The weighted kappa was 0.57 (95CE0.20 to 0.94)

Hara AK et al AJR, 2008
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Crohns DiseaseMR Enterography (MRE)
T2 weighted image (fluid bright)
T1 weighted image (walls bright)
Courtesy of Jeff Fidler, MD
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MRE and CTE Correlate with Colonoscopy

• MRE findings compared to colonoscopy and
  ileoscopy MRE correlates with CDEIS and this was
  validated in a subsequent study
• MRE vs CTE vs Ileocolonoscopy CTE and MRE were
  equally accurate for assessing disease activity

What we dont know Is mucosal healing or
transmural healing or histologic remission
responsible for better clinical outcomes?
Rimola J et al. Gut 2009581113-1120 Rimola J et
al. IBD 2010 Fiorino G et al. IBD
2011171073-1080
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CTE vs MRE
CTE
MRE

• CTE takes 10 seconds
• MRE takes 30 minutes
• With MRE, patients have to hold breath
• Worse in obese patients or respiratory problems
• Suboptimal MRE more common than CTE

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Bottom Line

• MRE and CTE show good correlation for the
  detection and localization of transmural CD
• Compared to CE, MRE and CTE are inferior in the
  detection of superficial mucosal disease
• CE may be more sensitive than CTE or MRE,
  especially in proximal SB

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Follow Known CD
Suspected No Fistula/ CD stricture Strictures a
bscess Ileoscopy CE CTE/MRE SBFT
A
B
A
A
B
C
C
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Deep EnteroscopyTube or Balloon Assisted
Enteroscopy

• Double-Balloon Enteroscopy (DBE)

Single-Balloon Enteroscopy (SBE)
Spiral Overtube Enteroscopy
Forcep channel allows biopsy and therapy
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DBE
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Impact of DBE on CD

• Prospective study of CD patients suspected of SB
  involvement in whom distal activity had
  previously been excluded
• Results
• 35 patients (70) showed SB lesions
• 23 (46) could not be assessed by conventional
  endoscopy
• Step up therapy in 26 patients (74) led to
  clinical remission in 23 (88)

Mensink PB et al. Scan J Gastro 201045483-489
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ComplicationsU.S. Data

• DBE unsucessful in 26 with Crohn disease
• 4/8 rectal DBE perforations occurred in patients
  with prior ileoanal or ileocolonic anastomoses
• In the subset of patients with available data
  regarding prior intestinal surgeries,
  perforations occurred in 6/76 (8) patients

Gerson L et al DDW 2008
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Diagnosis and Treatment of SB Strictures with DBE

• 156 patients with strictures underwent DBE
• Inflammatory disease in 87 and of those, Crohns
  disease in 57
• Balloon dilation in 31 with long term success in
  22 (71)
• 19 patients with symptomatic SB strictures and CD
• DBE detected 28 strictures
• 10/19 had 13 strictures from 1-4cms and underwent
  15 DBE balloon dilations
• Therapeutic success was achieved in 8 patients.
  No complications occurred

Fukumoto A et al GI Endo 66S108, 2007 Pohl J et
al Eur J Gastro Hep 200719529-534
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DBE for CE Retrieval

• 8/904 patients had capsule retention and caused
  acute SBO in 6 patients
• All capsules were successfully removed during DBE
• 5 patients underwent elective surgery for
  underlying cause
• One patient required emergency surgery because of
  multiple SB perforations

Van Weyenberg SJB et al GIE 2010535-541
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Capsule Retrieval with BAE
Courtesy of Mark Stark
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New Small Bowel Imaging TestsComplimentary

• Capsule Endoscopy (CE)
• Excellent mucosal detail non-invasively
• Identifying CD missed with conventional endoscopy
• Evaluating extent and severity of SB involvement
• CT and MR Enterography (CTE/MRE)
• Transmural assessment
• Extraintestinal lesions
• Balloon-Assisted Enteroscopy (BAE)/ Rotational
  Enteroscopy
• Mucosal detail
• Allows for biopsy and therapeutics

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Approach to Suspected Crohns Disease of the
Small Bowel
Suspected Crohns Disease of SB
Positive Ileocolonoscopy
Negative Ileocolonoscopy or unsuccessful
No obstruction
Possible or know obstruction
Agile patency capsule
either/or
Obstruction
No obstruction
Capsule endoscopy
CTE/MRE and/or DBE
Crohns disease of SB
Diagnose and Treat accordingly
SBCDSmall Bowel Crohns Disease CTECT
Enterography MREMR Enterography SBFTSmall
Bowel Follow Through
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Thank You!!