Capsule Endoscopy by: Given Imaging

Capsule Endoscopy by: Given Imaging

Agile Patency Procedure and PillCam SB for Suspected Small Bowel Crohn's Disease in Known Colitus and lleitis 


Stanley Cohen, MD  
Medical Director, Combined Center for Inflammatory Bowel Disease, Children’s Center for Digestive Health Care, Children’s Healthcare of Atlanta and Adjunct Clinical Professor of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA 

Patient History

A 17-year-old female presented with unexplained symptoms not responsive to her existing IBD therapy (for known colitis and ileitis). She had initially developed diarrhea, abdominal pain, fatigue, weight loss, and anemia 5 years prior to presentation. Colonoscopy at that time revealed active colitis in the cecum and hepatic flexure. Small bowel follow-through (SBFT) showed narrowing of the terminal ileum. She was placed on 6-MP with prednisone as a bridge until the 6-MP could take effect.

 A year prior to her current presentation, she had an ileocolonic resection for a 15 cm terminal ileal stricture, and stricturoplasty for 3 small strictures in mid-jejunum. There was no evidence of disease in the remainder of the small bowel at surgery. Post-op she was placed on 6-MP—however, the patient continued to have left lower quadrant pain and fatigue. Several months after surgery, esophagogastroduodenoscopy (EGD) was normal and colonoscopy showed a normal appearing colon but moderate inflammation in the ileum on biopsy. Her condition remained relatively stable; occasional mild disease flares were treated with metronidazole and hyoscamine.

Previous Diagnostic Procedures

A recent computed tomography (CT) scan showed thickened ileum and sigmoid narrowing when she had been re-hospitalized for epigastric pain, nausea and vomiting. Her 6-MP was changed to methotrexate. However, she persisted with diarrhea, fatigue, hematochezia on only one occasion, and anemia. Colonoscopy showed active ulceration in the colon and ileum. Biopsies demonstrated minimal colitis and mild to moderate ileitis. However, several questions remained related to her disease and management: What if the disease was more diffuse? What was the appropriate therapy?

Therefore, a PillCam SB capsule endoscopy (CE) was proposed to assess small bowel involvement. Due to concern of suspected strictures based on patient history and recent CT, the Agile patency procedure was performed prior to CE to assure safe passage of the PillCam SB video capsule.

Pill Cam Findings

The PillCam SB video capsule revealed diffuse Crohn’s disease lesions and ulcerations in the proximal small bowel (see images on this page).

Patient Management and Follow-up

According to our clinic’s practice (to educate patients about their disease and to encourage patient compliance with treatment), the patient and her parents were shown her PillCam SB images of Crohn’s disease. This was crucial in convincing the patient and parents that a change in treatment course was necessary—specifically, they wanted a logical rationale in directing further therapy in light of the potential for side effects with different medication regimens. The patient is now doing well following her induction phase with infliximab [only 2 months]. Although not currently scheduled, her parents would like her to have a follow-up CE to monitor her progress.

Conclusion

The Agile patency procedure followed by CE with the PillCam SB video capsule confirmed that this patient (with known IBD) had small bowel disease that was not seen on previous surgery, colonoscopy, or CT. It resulted in defining previously unrecognized areas of involvement with more extensive ulceration than expected. The CE findings led to a change in diagnosis that resulted in a change of patient management that improved patient outcomes. The patient continues to do well.

Images and Videos

CT Image
CT image shows suspected strictures; thickened ileum and sigmoid narrowing


Diffuse Crohn's disease lesions and ulcerations in the proximal small bowel
PillCam SB PillCam SB PillCam SB
     
     

About the Author

Stanley Cohen, MD

Dr Stanley Cohen is Medical Director of the Combined Center for Inflammatory Bowel Disease, Children’s Center for Digestive Health Care, Children’s Healthcare of Atlanta and Adjunct Clinical Professor of Pediatrics at Emory University School of Medicine in Atlanta, Georgia. Dr Cohen has been involved with CE since 2001. He was the USA principal investigator for the clinical trials of the Agile patency capsule in pediatric patients as well as the initial pediatric trials for Given Imaging’s first video capsule for the small bowel, the M2A®. Dr Cohen is an active participant at international conferences and research on IBD and nutrition.

 


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