Use of Capsule Endoscopy to predict disease exacerbation in Crohn s disease

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1 Use of Capsule Endoscopy to predict disease exacerbation in Crohn s disease Rami Eliakim Department of Gastroenterology, Sheba Medical Center, Tel-Aviv, Israel

2 Capsule Endoscopy Findings in patients with documented Crohn s Disease 2

3 Diagnostic yield of CE Vs. other modalities SBFT CTE Established CD IC Dionisio PM et al. Amer J Gastroenterol 2010; 105:

4 Potential roles for CE in known CD:. Assess therapeutic success in terms of mucosal healing. Clarify discrepancies between symptoms and lab results. Detect new findings and impact management. Prognostic tool: - before or after treatment - post surgery

5 How do we assess relapsing symptoms? CDAI FCP Physical exam Direct and Indirect Visualization Capsule Endoscopy Ileocolonoscopy CTE/MRE Brotman M, et al. Atlas on Crohn s Disease. Sulime Diseno DE Soluciones, S.L., Publisher;

6 Prospective Israeli IBD Research Network (IIRN) study looking at ways to predict relapse in patients with know CD Eliakim R, Lahat A, Amitai M, Yablekowitz D, Neuman S, Levhar N, Kopylov U, Ben-Horin S Chaim Sheba Medical Center Tel Hashomer, Israel

7 Aim: to recruit 80 CD pts in steroid free remission (>3M-<2y), or mild disease (CDAI<220) and follow them prospectively for 3y Develop an algorithm to predict relapse

8 Methods: Prospective, none interventional study MRE, Patency capsule, PillCam SB3 or CCE2 at inclusion and then every 6M (capsule) and yearly (MRE) Extensive lab F/U q3m- CBC, FCP, CRP, other markers of inflammation

9 Complications: is CE safe in CD? 7-13%

10 Parylene Coating Exposed Windows at Both Ends Timer Plugs Lactose Body w/ 10% Barium RFID tag Principles of Operation Stays intact for minimum 30 hours post-ingestion. Disintegrates after 30 hours postingestion in GI tract. Emits electromagnetic waves at 64 KHz when sensing electromagnetic waves at 128 KHz. 12mm Agile Patency Capsule 10

11 Day 0: Liquid diet from noon NPO at 10 pm Day 1: Morning ingestion Day 2: Scanning* (close to but not later than 30 hours) Patency proven (capsule not detected in body) Patency NOT proven (capsule detected in patient s body) Capsule disintegrates after 30 hours. *If Agile Patency Scanner is contraindicated, use fluoroscopy. Agile Patency Procedure

12 The Lewis inflammation score SB divided into 3 tertiles according to small bowel passage time <135=N; = mild; >790 = mod-severe inflammation

13 Results Demographic Data Characteristics CD (n=67) Male/female 38/29 Age 31±10 Duration (years) 7±6 Non-smoker 46 (69%) Ex-smoker 8 Smoker 13 Disease location Current treatment L1-28, L3-34, L2-4, L4-1, Perianal-17 5-ASA-6;IM- 35 (52%); Biologics- 28 (42%)

14 Results: 47 capsule 47 capsules passed 61 patency* 67 MRE 3 withdrew consent 2 MRE showed severe stenosis (screen failure) 1 flare 13 capsules retained (screen failure) 1 withdrew consent none retained Flow Chart

15 MRE prediction of capsule retention Vs. patency capsule Vs. regular capsule Patency will not retain Patency will retain MRE Patency results Total number of patients who took the patency: 61 2 patients with retained patency were not predicted by MRE If we were to give regular capsules via MRE prediction >twice of patients would be denied Sensitivity - 85%; Specificity - 58%; PPV - 35%; NPV - 93% 48 13

16 What do we mean by remission? All patients with CDAI <150 (+ steroid free >3M) 12 of 47 in endoscopic remission (25%) (LS <135) 4 of 47 in biomarker remission (19%) (CRP<5; FCP<30) So 4 of 47 (9%) are in deep remission 8 of 12 on biological therapy (1+IM); 4 of 12 on IM

17 Anatomic Distribution of active SB disease (n=47) Pre-study Proximal + Middle (1pt) Distal (97%) 1 st CE 28 (60%) 29 (62%) 1 st MRE 12 (25%) 34 (72%) No Disease 12 (25%) 11 (23%) Calculated MRE sensitivity for proximal disease compared to CE= 35%; P=0.007

18 CRP & FC in Patients with Any SB Involvement in CE (n=35) CE CRP (>5mg/l) FC (>30µg/g) 5 CRP<10 30<FC<100 7 (20%) 6 (17%) 100 FC<300 CRP (40%) FC (11%) 9 (26%) Total 10 (28%) 30 (86%)

19 9% Relapsed/excluded (6/67): last LS (<135) last CRP (<5) last FC (<30) ZS (3M) AK (6M) EK (1M) >300 GB (3M) >300 AK (2M) >300 OR (3M) >300

20 Summary: CE is safe in patients with Known CD, when PC is used for screening >50% of patients have PSB disease (L4a,L4b) via CE that is mostly not seen on MRE CDAI & CRP do not correlate with SB mucosal injury FCP is much more sensitive than CRP for SB mucosal injury Most people that are in clinical and routine laboratory remission have SB mucosal injury Long term significance of these findings remains to be seen

21 THANK YOU FOR YOUR ATTENTION!!!!