Diagnostic Accuracy of Fecal Calprotectin for the Detection of Small Bowel Crohn’s Disease through Capsule Endoscopy: An Updated Meta-Analysis and Systematic Review

( Eun Suk Jung ),( Sang Pyo Lee ),( Sea Hyub Kae ),( Jung Han Kim ),( Hyeong Su Kim ),( Hyun Joo Jang ) 대한소화기학회 2021 Gut and Liver Vol.15 No.5

Background/Aims: The diagnosis of small bowel Crohn’s disease with negative ileocolonoscopic findings has been challenging. Fecal calprotectin (FC) has been used to detect colonic inflammation, but its efficacy for detecting small bowel inflammation is less established. We performed an updated meta-analysis to evaluate the diagnostic accuracy of FC to detect active small bowel inflammation observed during capsule endoscopy. Methods: We conducted a systematic literature search for studies that evaluated the correlation between small bowel inflammation and FC in patients with suspected/established Crohn’s disease. We calculated the pooled sensitivity, specificity, and diagnostic odds ratios (DORs) and constructed hierarchical summary receiver operating characteristic curves for FC cutoffs of 50, 100, and 200 μg/g. Results: Fourteen studies were eligible for the final analysis. The DORs of all FC cutoffs were significant. The highest DOR was observed at 100 μg/g (sensitivity, 0.73; specificity, 0.73; and DOR, 7.89) and was suggested as the optimal diagnostic cutoff. If we analyzed only studies that included patients with suspected Crohn’s disease, the DOR was 8.96. If we analyzed only studies that included patients with a Lewis score ≥135 as a diagnostic criterion for active disease, the DOR was 10.90. Conclusions: FC has significant diagnostic accuracy for detecting small bowel inflammation, and an FC cutoff of 100 μg/g can be used as a tool to screen for small bowel Crohn’s disease. (Gut Liver 2021;15:732-741)

Clinical management for small bowel of Crohn’s disease in the treat-to-target era: now is the time to optimize treatment based on the dominant lesion

( Kenji Watanabe ) 대한장연구학회 2020 Intestinal Research Vol.18 No.4

A treat-to-target strategy, in which treatment is continuously adjusted according to the results of scheduled objective monitoring, is optimal for patients with Crohn’s disease (CD) in the era of biologics. The small bowel is a common site of intractable CD, which may result from multiple strictures or expanding lesions. To improve the prognosis of patients with small bowel CD, lesions should be proactively monitored within the subclinical phase. Objective assessment of small bowel lesions is technically difficult, however, due to the relatively poor correlation between endoscopic activity and clinical symptoms or biomarker titers. The presence of proximal small bowel lesions and asymptomatic “Real Silent CD” must be considered. Endoscopy remains the gold standard to assess these lesions. In clinical practice, the advantages and disadvantages of each imaging modality and biomarker must be carefully weighed for appropriate application and reliable monitoring. The prevalence of small bowel lesions depends on the precision of the imaging modality used for detection. Clinical management should be based on the dominant location of the intestinal lesions rather than classical classification. Optimal strategies for detecting and treating small bowel lesions in patients with CD must be developed utilizing reliable, precise, and objective monitoring. (Intest Res 2020;18:347-354)

Balloon-Assisted Enteroscopy and Capsule Endoscopy in Suspected Small Bowel Crohn’s Disease

Hsu-Heng Yen,Chen-Wang Chang,Jen-Wei Chou,Shu Chen Wei 대한소화기내시경학회 2017 Clinical Endoscopy Vol.50 No.5

Inflammatory bowel diseases are idiopathic inflammatory diseases of two main types, Crohn’s disease and ulcerative colitis. Crohn’s disease can affect the entire gastrointestinal tract, and the distal ileum is involved in up to 70% of patients. Moreover, Crohn’s disease in one-quarter to one-third of patients involves isolation of the small bowel. Due to the nonspecific symptoms and anatomical location of the disease, small bowel Crohn’s disease is a phenotype that is particularly difficult to manage. Since the introduction of capsule endoscopy in 2000 and balloon-assisted enteroscopy in the 21st century, it is now possible to directly inspect for small bowel Crohn’s disease. However, the new modalities still have limitations, such as capsule retention and invasiveness of balloon-assisted enteroscopy. The diagnostic yields of both capsule endoscopy and balloon-assisted enteroscopy are high for patients with suspected small bowel Crohn’s disease. Therefore, earlier use of capsule endoscopy or balloon-assisted enteroscopy can help with the diagnosis and earlier treatment of these patients to avert possible disastrous outcomes.

소장 크론병의 PET-CT 경험 1예

박윤선 ( Youn Sun Park ),김국현 ( Kook Hyun Kim ),최재원 ( Jae Won Choi ),은종렬 ( Jong Ryul Eun ),장병익 ( Byung Ik Jang ),김태년 ( Tae Nyeun Kim ) 대한장연구학회 2006 Intestinal Research Vol.4 No.1

Endoscopic and radiologic studies are frequently required in inflammatory bowel disease to determine disease activity, extent of disease, and delineating type. Positron emission tomography (PET) using fluorine-18-fluoro-deoxyglucose to identify metabolically active tissues may offer a simple noninvasive alternative to conventional studies in identification and localization of active intestinal inflammation with inflammatory bowel disease. Crohn`s disease can also be detected by PET-CT. In this case, we discribe a small bowel Crohn`s disease with PET-CT finding. There was intensely increased fluorine-18-fluoro-deoxyglucose uptake in terminal ileum area. (Intestinal Research 2006;4:57-60)

소장 질환이 의심되는 소아에서 캡슐 내시경의 유용성

박혜진,이소연,고재성,서정기 대한소화기내시경학회 2009 Clinical Endoscopy Vol.39 No.6

Background/Aims: The aim of our study is to investigate the diagnostic value and safety of capsule endoscopy (CE) in the pediatric patients with small bowel (SB) disease. Methods: We retrospectively reviewed the records of 29 children (mean age: 11.8 year) who underwent CE at Seoul National University Children’s Hospital between November 2004 and April 2009. Results: Six (20%) of the total 29 patients could not swallow the capsule (mean age: 10.5 years), so the capsule was endoscopically placed into the stomach of these 6 patients. The CE examination for the entire SB was finished in 89.6% of the patients. The indications for CE studies were obscure gastrointestinal bleeding (OGIB) or anemia in 14 patients, intestinal polyposis in 8, abdominal pain in 4 and Crohn’s disease in 3. The diagnostic yield of CE was 35.7% for OGIB or anemia, 37.5% for intestinal polyposis, 25% for abdominal pain and 33.3% for Crohn’s disease. One patient had capsule retention during our CE investigations. Conclusions: CE is a safe and valuable tool for the detection of SB Crohn’s disease, the focus of OGIB and the presence of SB polyps in pediatric patients. 목적: 소장은 몸의 중심에 위치하며 길이가 길고 구불구불한 특성이 있어 관찰하기가 쉽지 않다. 2000년 처음으로 도입된 이후 캡슐 내시경은 사용이 확대되고 있는데 소아에서의 경험이 많지 않기에 이번 연구에서는 캡슐 내시경의 유용성과 안전성을 평가하기로 하였다. 대상 및 방법: 2004년 11월부터 2009년 4월까지 위장관 출혈, 빈혈, 폴립, 복통 등의 증상으로 서울대학교병원 어린이병원에 내원하여 캡슐 내시경검사를 시행받은 29명의 환자를 대상으로 하였다. 캡슐 내시경을 시행하기 전 환자들은 최소 8시간 금식하였고 캡슐 내시경을 삼키지 못하는 경우 EGD를 이용하여 위에 캡슐 내시경을 위치시켰으며 캡슐 내시경의 배출은 대변으로 내시경을 확인한 것으로 하였다. 검사에 사용된 캡슐 내시경은 Pillcam (GIVENⓇ, Imaging Ltd., Israel)이었다. 결과: 총 29명 중 6명에서 캡슐 내시경을 삼키기가 불가능하여 EGD를 이용하여 위에 투여하였다. 환자들의 증상이나 질환은 10명이 혈변, 8명이 장 폴립증, 4명이 원인을 알 수 없는 빈혈, 4명이 타 검사로 설명되지 않는 복통, 3명이 크론병이었다. 혈변이나 빈혈이 있었던 14명 중 5명(35.7%)에서 소장의 출혈 병소가 관찰되었다(혈관 형성 이상 1명, 창자 혈관종 1명, 궤양 3명). 폴립 증후군으로 캡슐 내시경을 시행한 8명 중 3명(37.5%)에서 소장의 폴립이 발견되었다(가족 샘 폴립증으로 진단된 2예 중 1예, 포이츠-예거 증후군으로 진단된 5예 중 2예). 크론병으로 진단받은 환자 3명 중 1명(33.3%)에서 소장 병변이 관찰되었다. 원인을 알 수 없는 복통으로 캡슐 내시경을 시행한 4명 중 1명(25%)에서 원인(크론병)을 발견할 수 있었다. 총 29명 중 1명(3.4%)에서 캡슐 내시경이 결장에 정체되었지만 장관의 막힘은 없었다. 결론: 소장 질환이 의심되는 소아에서 다른 검사법으로 병변을 찾을 수 없을 때 캡슐 내시경은 진단과 치료 방침을 결정하는데 도움이 되며 안전한 검사이다.

Mechanism-based Drug Therapy of Inflammatory Bowel Disease With Special Reference to Rheumatic Disease

Jae Jun Park 대한류마티스학회 2020 대한류마티스학회지 Vol.27 No.3

Inflammatory bowel disease (IBD), comprised of Crohn’s disease and ulcerative colitis, is a chronic, relapsing, and remitting disease of the gastrointestinal tract whose incidence is rising worldwide, especially in East Asian countries. The etiopathogenesis of IBD remains poorly understood. It is currently considered that a combination of genetic and environmental factors triggers an aberrant immune response against the commensal intestinal flora in IBD patients. Over the past decades, advances in the knowledge of the inflammatory cascade involved in IBD pathogenesis have expanded the pharmacological armamentarium in IBD. Actually, the introduction of specific biological therapies, including anti- tumor necrosis factor, anti-interleukin- 12/23, and anti-integrin, has revolutionized the treatment of IBD. Moreover, small molecule agents such as Janus kinase inhibitors also now under clinical use. In IBD, a substantial number of patient accompanies various articular manifestations and, rheumatic involvement is one of the most common extra-intestinal symptoms. Many of the mechanisms based drugs described above have already been used in rheumatic diseases. In addition, some of those drugs can be used to treat both IBD itself and accompanied rheumatic involvement, however there are differences in drug usage between these two indications. This review aims to briefly review the mechanism-based drug therapies of IBD with particular reference to rheumatic disease.