Capsule Endoscopy and Crohn’s Disease

We read with great interest the study by Herrerias et al. [1], and commend them for not only attempting ileoscopy in all 21 patients in their study but also for successfully intubating the ileum in 81 % of patients. In this study, patients with suspected Crohn's disease underwent capsule endoscopy (CE) if they had a normal colonoscopy (with terminal ileoscopy if possible) and a normal small-bowel follow-through; CE was found to be diagnostic of small-intestinal Crohn’s disease in nine of the 21 patients (43 %). These findings are noteworthy: had further evaluation with CE not been performed, these lesions would not have been visualized and a diagnosis of Crohn’s disease might have been significantly delayed.

Many gastroenterologists advocate that intubation of the ileum should be an integral part of colonoscopy, especially in the evaluation of patients with suspected Crohn’s disease or obscure gastrointestinal bleeding [2]. We agree with this and routinely perform ileoscopy during colonoscopy at our institution. However, endoscopic evaluation is often limited and only a short segment of the terminal ileum, usually the distal 8 - 10 cm, is adequately examined [3]. In this study by Herrerias et al., CE demonstrated ileal involvement in 43 % of patients despite a previous normal endoscopic examination of the ileum. In some patients, findings were seen in the proximal portion of the ileum, where lesions clearly may not have been within reach of the endoscope. This raises the question: how valuable is ileoscopy in patients with Crohn’s disease?

We suggest that capsule endoscopy is a better test for evaluating the terminal ileum and should be considered even if terminal ileoscopy is unrevealing in patients suspected of having Crohn’s disease. CE not only allows full visualization of the ileum, but also provides additional useful information on the degree and extent of disease in the remainder of the small bowel.

In conclusion, we advocate that ileoscopy and biopsy should be routinely and consistently performed as part of the evaluation of all patients with suspected Crohn’s disease. We also suggest that ileoscopy often provides only limited information, and one therefore should have a low threshold to proceed to CE as an additional test. We anticipate that future studies will demonstrate that CE is an essential and necessary diagnostic test in the work-up and evaluation of patients with suspected Crohn’s disease.

References

• 1 Herrerias J M, Caunedo A, Rodríguez-Téllez M. et al . Capsule endoscopy in patients with suspected Crohn’s disease and negative endoscopy.  Endoscopy. 2003;  35 564-568
• 2 Lewis B S. Ileoscopy should be part of standard colonoscopy.  J Clin Gastroenterol. 2000;  31 103-104
• 3 Bhasin D K, Goenka M K, Dhavan S. et al . Diagnostic value of ileoscopy.  J Clin Gastroenterol. 2000;  31 144-146