By Andres J. Yarur, MD

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Andres J. Yarur, MD
Assistant Professor
Division of Gastroenterology and Hepatology
Department of Medicine
Medical College of Wisconsin
Milwaukee, Wisconsin

Crohn’s disease (CD) is a chronic inflammatory bowel disease that can potentially affect the entire gastrointestinal tract. While the therapeutic arsenal for CD has been historically limited, during the last decade, newer therapeutic agents have become available and have dramatically improved outcomes, increasing the rate of intestinal mucosal healing and decreasing long-term complications. Treat-to-target strategies involve a regular assessment of disease activity and adjustment of therapy when needed in order to achieve mucosal healing.1 Because symptoms poorly correlate with intestinal inflammation, clinicians have been in need of newer objective tools to accurately assess CD activity.

There is no gold standard test to diagnose and/or monitor CD activity, but multiple endoscopic and radiological modalities have been developed and validated. Upper endoscopy with ileocolonoscopy has been one of the most important tests, especially when assessing mucosal healing (absence of endoscopic inflammation), but the visualization of the small bowel is limited to the duodenum and terminal ileum. Since capsule endoscopy (CE) was approved, it has been a powerful tool to help diagnose and monitor CD, particularly in the small bowel. CE has been found to be more sensitive than radiological tests and even ileocolonoscopy.2,3

Case Presentation

A 67-year-old man presented with an 8-week history of abdominal pain and involuntary weight loss. The pain was of moderate intensity and worsened after eating. There were no alleviating or aggravating factors. He had lost almost 12 pounds since he started experiencing the pain. He was only taking lisinopril for hypertension and denied the use of nonsteroidal anti-inflammatory drugs. Laboratory results showed a normocytic-normochromic anemia (hemoglobin, 11.2 g/dL) and elevated C-reactive protein (20 mg/dL). An upper endoscopy with biopsies was normal, and a colonoscopy showed a normal macroscopic colon and 10 cm of the terminal ileum.

Nevertheless, biopsies of the terminal ileum showed changes of acute and chronic inflammation. Magnetic resonance enterography showed evidence of patchy inflammation throughout the ileum with wall thickening and mesenteric inflammation. CE was performed, showing multiple large ulcerations in the jejunum and ileum (A). The patient was diagnosed with CD and started on combination therapy with infliximab and azathioprine. After 4 weeks, he was asymptomatic. CE was performed again after 14 weeks of beginning therapy and showed an improvement in the level of inflammation, but persistent ulcers (B). Infliximab levels were measured and recorded as 2 mcg/mL. The dose of infliximab was adjusted accordingly, and a new CE was done 26 weeks after the drug was originally started and showed complete resolution of the ulcerations (C).

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Images courtesy of Andres J. Yarur, MD.

Discussion

Treat-to-target strategies in CD require objective markers of inflammation as symptoms poorly correlate with endoscopic disease activity. CE is a highly sensitive, noninvasive method of monitoring patients with CD and small-bowel involvement that can be useful to assess disease activity and subsequently adjust therapy in order to achieve mucosal healing and ultimately improve long-term outcomes.

References

  1. Bouguen G, et al. Treat to target: a proposed new paradigm for the management of Crohn’s disease. Clin Gastroenterol Hepatol. 2015;13(6):1042-1050.e2.
  2. Dubcenco E, et al. Capsule endoscopy findings in patients with established and suspected small-bowel Crohn’s disease: correlation with radiologic, endoscopic, and histologic findings. Gastrointest Endosc. 2005;62(4):538-544.
  3. Dussault C, et al. Small bowel capsule endoscopy for management of Crohn’s disease: a retrospective tertiary care centre experience. Dig Liver Dis. 2013;45(7):558-561.