Development of significant disease in a cohort of patients with non-specific enteritis on capsule endoscopy. Clinical suspicion and a high base line Lewis score are predictive of Crohn’s disease.

Abstract

Introduction: As with isolated ileitis the findings of nonspecific small bowel enteritis (NSE) on capsule endoscopy (CE) poses a clinical challenge. There is lack of available evidence to help clinicians to predict significant disease and long-term prognosis.Aim: To define the natural history of NSE in an Irish cohort. Methods: Patients with a finding of NSE were identified from a database. Subsequent investigations, treatments and diagnosis were recorded. Patients were grouped based on ultimate diagnosis: Crohn’s disease (CD), Irritable bowel syndrome (IBS), NSAIDs enteritis (NSAIDs), persistent NSE and no significant disease (NAD).Results: 88 patients, 46 (52%) male, mean age 52 +- 17.8 years were included with a mean follow up of 23 +- 19 months. The ultimate diagnoses were NAD=43 (49%), CD =17 (19%), IBS =14 (16%), NSAIDs =12 (14%) and persistent NSE=2 (2%). Significantly, more patients diagnosed with CD on follow up were referred with suspected CD. CD= 14/17 (82%) vs 13/57 (23%), p < 0.001. While a diagnosis of CD was associated with a positive baseline Lewis score (>135); 11/17 (65%) CD versus 16/ 71 (23%). Female gender was associated with an ultimate diagnosis of IBS (OR 5, p <0.02). Older age was associated with NSAIDs enteritis, while more subjects without significant gastrointestinal disease were anemic on presentation.Conclusion: The majority (49%) of NSE patients do not develop significant small bowel disease. CD occurred in 19% of NSE patients on follow up. Clinical suspicion and capsule severity are predictive of Crohn’s disease on initial CE.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022

“…A retrospective observational study by Freitas et al 97 investigated 102 patients found to have “isolated terminal ileitis” at ileocolonoscopy, endoscopic abnormalities proximal to the terminal ileum were found in 36.3 % of patients; one third (35/102) were finally diagnosed with CD. Similarly, isolated ileitis on SBCE can frequently herald an ultimate diagnosis of CD, even in patients with an initial negative ileocolonoscopy 98 99 .…”

Nonspecific ileitis: Impact of histopathology and gastrointestinal ultrasound in achieving the diagnosis of Crohn's disease

“…In 88 patients undergoing capsule endoscopy and found to have nonspecific enteritis with scattered small erosions or aphthous ulcers with minimal or mild inflammation, 19% were later diagnosed with Crohn's disease. 6 In another retrospective study of 108 patients with isolated terminal ileitis with a median follow-up time of 54.7 months, 5 (4.6%) developed Crohn's disease after a median of 32.3 months. 7 Another study has shown a progression rate of 14% from isolated ileitis to Crohn's disease, with isolated ileitis cases having excess NOD2 mutations, similar to those with Crohn's disease.…”

“…In the capsule study, patients were followed up with endoscopy most commonly, or repeat capsule endoscopy and other small bowel imaging studies, to aid a final diagnosis or the cause for the enteritis. 6 Imaging with barium studies, computed tomography (CT), radiolabeled white cell scans, and visceral angiography have been shown to be useful in defining abnormalities in a single small case series with nonspecific small intestinal ulceration. 11 Applying such techniques to all those with incidental ileal lesions cannot be considered good clinical practice.…”

“…The worst case scenario is that the lesions are ignored and the opportunity to make a formal diagnosis of Crohn's disease early is lost. In 88 patients undergoing capsule endoscopy and found to have nonspecific enteritis with scattered small erosions or aphthous ulcers with minimal or mild inflammation, 19% were later diagnosed with Crohn's disease 6 . In another retrospective study of 108 patients with isolated terminal ileitis with a median follow‐up time of 54.7 months, 5 (4.6%) developed Crohn's disease after a median of 32.3 months 7 .…”