Small Bowel Evaluation Choosing the Best Radiologic and

Small Bowel Evaluation – Choosing the Best Radiologic and Endoscopic Modalities Jonathan A. Leighton, MD Mayo Clinic Arizona leighton. jonathan@mayo. edu Great Debates and Updates in IBD San Francisco, CA March 2013

Importance of Small Bowel Evaluation in Crohn’s 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 = Crohn’s disease; C+I = colonoscopy with ileoscopy.

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 Crohn’s disease

Case Study • 42 yo male with history of ileal Crohn disease diagnosed in 2001 in Chicago treated with 5 ASA • 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

Negative Colonoscopy and Ileoscopy

Negative MR Enterography

Positive CE

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 2012; 10: 1253 -59

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 > SBFT (P<. 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

CE and Suspected Crohn’s Disease Final 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 Crohn’s disease than confirming it • CE may play an even more important role in established CD Tukey M et al. Am J Gastro 2009; 104: 2734 -9 Levesque BG, et al. Clin Gastro Hep 2010; 261 -7 Goldfarb NI et al: Dis Manag 7: 292 -304, 2004

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 2011; 74: 167 -75

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 < 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 2011; 17: 1855 - 62

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 2012; 4: 185 -188

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

CT Enterography (CTE) • • • Oral contrast: Neutral Rate: 450 cc every 15 min Amt: 1350 cc over 45 min

Low Dose CT 30 -50% less radiation Filtered back projection Increased noise ASIR Software Decreased noise

CTE Differentiating Active vs Chronic CD N = 96 pts with CTE and endoscopy CTE Finding Sens (%) Mural hyperenhancement 80 Bowel wall thickening 75 Mural stratification 60 Comb sign 35 Inc. mesenteric fat atten 10 Bodily K et al: Radiology 2006; 238: 505 -516

Small Bowel Normal vs Crohn’s Disease Enhancement: Homogeneous Enhancement: Increased Distended Bowel Wall Thickness <3 mm Bowel Wall Thickness >3 mm

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 2012; 10: 1253 -59

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 (n=2) or improved (n=2) • Endoscopy correlated with CTE findings in 12/12 and with symptoms in 9/12 • The weighted kappa was 0. 57 (95%CE=0. 20 to 0. 94) Hara AK et al: AJR, 2008

Crohn’s Disease MR Enterography (MRE) T 2 weighted image (fluid bright) Courtesy of Jeff Fidler, MD T 1 weighted image (walls bright)

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 don’t know: Is mucosal healing or transmural healing or histologic remission responsible for better clinical outcomes? Rimola J et al. Gut 2009; 58: 1113 -1120 Rimola J et al. IBD 2010 Fiorino G et al. IBD 2011; 17: 1073 -1080

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

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

Follow Known CD Suspected No Fistula/ CD stricture Strictures abscess Ileoscopy A B CE B A CTE/MRE B A SBFT C A A B C

“Deep Enteroscopy” Tube or Balloon Assisted Enteroscopy Double-Balloon Enteroscopy (DBE) Single-Balloon Enteroscopy (SBE) Spiral Overtube Enteroscopy Forcep channel allows biopsy and therapy

DBE

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 2010; 45: 483 -489

Complications U. 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

Diagnosis and Treatment of SB Strictures with DBE 156 patients with strictures underwent DBE Inflammatory disease in 87 and of those, Crohn’s 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 -4 cms and underwent 15 DBE balloon dilations • Therapeutic success was achieved in 8 patients. No complications occurred Fukumoto A et al: GI Endo 66: S 108, 2007 Pohl J et al: Eur J Gastro Hep 2007; 19: 529 -534

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 2010; 535 -541

Capsule Retrieval with BAE Courtesy of Mark Stark

New Small Bowel Imaging Tests Complimentary • 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

Approach to Suspected Crohn’s Disease of the Small Bowel Suspected Crohn’s Disease of SB Positive Ileocolonoscopy Negative Ileocolonoscopy or unsuccessful Possible or know obstruction No obstruction Agile patency capsule No obstruction Capsule endoscopy either/or Obstruction CTE/MRE and/or DBE Crohn’s disease of SB Diagnose and Treat accordingly SBCD=Small Bowel Crohn’s Disease; CTE=CT Enterography; MRE=MR Enterography; SBFT=Small Bowel Follow Through

Thank You!!