Videocapsule endoscopy versus barium contrast studies for the diagnosis of Crohn's disease recurrence involving the small intestine.

OBJECTIVES: Historically, suspected Crohn's disease (CD) has been evaluated with small bowel follow-through (SBFT) or enteroclysis (equally accurate). This study was undertaken to determine the accuracy of videocapsule endoscopy (VCE) in the diagnosis of CD relative to SBFT and clinical/laboratory indices of CD activity. Previous investigations have used VCE for the diagnosis of suspected CD in patients presenting with a variety of gastrointestinal symptoms. This is the first study to evaluate the occurrence of active disease in patients with known CD.
METHODS: Thirty subjects (22 female, 8 male, aged 36.9 +/- 14.2 yr); all with prior CD diagnosis made on the basis of standard criteria (5.5 +/- 6.5 yr prior to study), in whom recurrent CD was suspected based on abdominal pain, diarrhea, anemia, and/or arthralgias. Subjects were studied in a prospective, blinded evaluation of VCE versus SBFT. SBFT was performed first; those with stricture and proximal bowel dilation were excluded from further study. For SBFT, studies were graded as grade 0 (normal), grade 1 (minimal nodularity, ulcerations, normal luminal diameter, < 5 cm involved), grade 2 (more extensive ulcers, minimal luminal narrowing, 5-10 cm involved), or grade 3 (fistula, skip areas, extensive ulceration, >10 cm involved). VCE was performed within 1 wk of SBFT. Serum was obtained for ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein), stool was obtained for alpha-1 antitrypsin, and the Harvey Bradshaw index of CD severity was calculated. VCE (digitalized video) was graded as grade 0 (normal), grade 1 (erythema, isolated villi loss), grade 2 (erosion, no ulcer), or grade 3 (ulcers, spontaneous bleeding, and/or stricture).
RESULTS: Twelve patients were excluded for small bowel obstruction. VCE and SBFT scores highly correlated (r = 0.65; p= 0.001). Active CD was visualized in 21 of 30 patients with videocapsule endoscopy and in 20 of 30 patients with SBFT. Complete agreement occurred in 13 of 30 studies; 13 of 17 studies differed by one grade. SBFT found mucosal disease in 20 of 30 patients and VCE found mucosal disease in 21 of 30 patients. VCE found mucosal disease in 6 patients (5 in grade 1, 1 in grade 3) with normal SBFT. SBFT showed CD in 5 patients (all grade 1) with normal VCE. Neither VCE nor SBFT scores correlated with biological or clinical indices. Patient satisfaction was superior for VCE.
CONCLUSIONS: VCE and SBFT are complementary for the diagnosis of CD. SBFT may be required to detect strictures as the videocapsule may not pass. However, some strictures may also be missed with SBFT. VCE is less invasive, less time-consuming for the patient than SBFT, and avoids radiation exposure, although reading time is greater for the gastroenterologist than the radiologist. Given that patients with clinically suspected CD recurrence may not have active disease, unnecessary and potentially harmful empiric therapy is not warranted without imaging.