Patient with Crohn’s disease with previous ileocaecal resection for ileal stenosis.
Diagnosis by endoscopic capsule of post-surgical recurrence
The patient is a 54-year-old woman who was diagnosed with ileal stenosing Crohn’s disease (A3L1B2) 15 years ago, which required ileocaecal resection for bowel obstruction. She was receiving infliximab treatment before the surgery, without adequate response, and is intolerant to thiopurines.
One year after the surgery, the patient reported occasional symptoms of abdominal pain and diarrhoea, alternating with asymptomatic episodes. A repeat colonoscopy was performed but the ileocolic anastomosis and the ileal loop could not be adequately assessed, due to highly angulated anastomosis, preventing correct examination. We were also unable to correctly evaluate the patient by magnetic resonance enterography (MR enterography) as she is claustrophobic, so we decided to perform an endoscopic capsule (EC) examination to evaluate post-surgical recurrence, following the performance of a bowel transit, which rules out the existence of stenosis of the intestinal lumen, which would contraindicate the use of this capsule.
The patient’s physical examination was normal. The lab tests performed found all parameters to be within normal range, except for C-reactive protein (CRP), which shows a slight increase: 13 mg/l (normal range 0–5) and faecal calprotectin at a level of 450 µg/g (normal range 0–50 µg/g).
Endoscopic capsule study
This showed inflammatory involvement of the last 15 cm of the terminal ileus with a slightly decreased calibre of the ileocolic anastomosis (0.7 cm), although the contrast was sufficiently able to pass through (Fig. 1).
Endoscopic capsule study
The total EC transit time was 8 hours and 30 minutes, which allowed visualisation up to near the ileocolic anastomosis, without the EC passing through the anastomosis itself (Video 1).
In the distal jejunum we observed several isolated ulcers of around 5 mm in size, with stretches of normal mucosa. This involvement is more intense closer to the ileum, finding multiple larger, longitudinal ulcers that, in some areas, appear in all 4 quadrants, occupying an extensive area of involvement; there is mild degree of stenosis in the most distal part of the ileum, slowing the progress of the EC, although this did not cause retention and the EC was able to pass through the stenosis.
The endoscopic findings suggest an extensive and severe recurrence of Crohn’s disease, with a certain degree of inflammatory distal stenosis, which would be compatible with grade IV post-surgical recurrence, according to Rutgeerts’ classification.
FIRST TREATMENT APPROACH
Following the diagnosis of severe post-surgical recurrence in a patient previously treated with infliximab (>3 years), who is intolerant to thiopurines, we started adalimumab treatment at an induction regimen of 160 mg/80 mg, weeks 0 and 2, subcutaneously, continuing with maintenance at 40 mg/2 weeks.
The patient showed clinical improvement, remaining free of pain, with a normal bowel movement frequency, although the inflammation parameters continued to be slightly elevated: CRP and calprotectin.
We performed a repeat EC 6 months after starting the anti-tumour necrosis factor (anti-TNF) treatment, to assess changes in the intestinal involvement.
Repeat endoscopic capsule study
Situation: patient in clinical remission with elevated inflammatory parameters (CRP and calprotectin).
This was a caecal transit with a transit time of 2 hours and 33 minutes (Video 2). Compared to the previous study, we observed a reduction in the size of the ulcers in the proximal regions, maintaining a similar extension. The distal involvement remained striking, maintaining a similar extension of lesions although with decreased oedema, leading to improved motility and less retention of contents; we noted that the area of the ileocolic anastomosis was easily passable.
The severity of the lesions remained compatible with grade 4 recurrence, according to Rutgeerts’ classification.
SECOND TREATMENT APPROACH
The patient’s clinical improvement continued for the first week following treatment administration, but she was worse in the second week, improving again upon administration of the drug. Taking this into account, together with the lack of clear endoscopic improvement and the persistence of inflammatory analytic parameters (CRP and calprotectin), we decided to increase the treatment to 40 mg of adalimumab per week.
On this regimen, the patient remained symptomatically stable, with episodes of mild iron-deficiency anaemia (Hb 10.8–11.2 g/dl) that responded to oral iron treatment, with slight CRP (15–20 mg/l) and calprotectin (450–700 µg/g) elevation. Over time, self-limiting episodes of pain and abdominal distension started to develop related to the ingestion of certain foods.
After one year, we performed another repeat EC:
ENDOSCOPIC CAPSULE AFTER 1 YEAR OF INTENSIFIED TREATMENT (Video 3)
We compared this to the previous study and found no improvement. There was a notable delay in all transit times; in fact, despite a total transit time of almost 9 hours, the capsule was not able to pass through the ileocolic anastomosis.
The most significant involvement was still observed in the distal ileum, with severe inflammatory involvement and extensive, longitudinal and confluent ulcers.
The degree of recurrence continued to be comparable with grade 4 of Rutgeerts’ classification.
Due to the current condition of the patient,
who continues to experience clinically overt episodes related to her disease, the lack of endoscopic response and the persistence of analytic abnormalities, and given the low current effectiveness of adalimumab treatment, we decided to suspend this, starting methotrexate treatment at an initial dose of 25 mg/week intramuscularly (i.m.) followed by maintenance at 15 mg/week i.m.
Clinical response to the treatment was adequate, with an initial disappearance of the episodes of pain and distension and a normalisation of the analytic abnormalities, including calprotectin and CRP.
After 18 months of treatment with methotrexate, a repeat fibroscan was performed, which showed no signs of hepatic fibrosis.
Over time, although to a lesser extent than with previous treatments, the patient again started to occasionally present episodes of mild iron-deficiency anaemia that responded to oral iron treatment and a transitory elevation of CRP and calprotectin.
As almost 2 years had passed since the last repeat EC, and due to the possibility of the patient having developed intestinal stenosis (mucosal healing was not demonstrated at any point and the patient continued to experience isolated episodes of activity), we decided to evaluate the disease by computed tomography enterography (CT enterography), due to the limitations on using colonoscopy and MR enterography with this patient.
COMPUTED TOMOGRAPHY ENTEROGRAPHY STUDY (Video 4, Fig. 2 and Fig. 3)
We observed stenosis of the ileocolic anastomosis and of approximately 10 cm of the distal neo-ileum, with a partial decrease of the lumen. We observed no prestenotic dilation. There was wall thickening, although with mixed characteristics, with a primarily fibrotic with exclusively mucosal contrast enhancement.
We have decided to continue the s.c. methotrexate treatment, as the patient has shown good tolerance to it and the treatment has achieved a better clinical response, at least so far.
We will perform periodic clinical-analytical monitoring and periodic fibroscans as follow-up for the appearance of hepatic fibrosis.
Based on progress, we suggest performing a CT enterography study if complications or progression of stenosis are suspected due
to the appearance of sub-occlusive symptoms.
SUPPORTING SCIENTIFIC UPDATE
• II.5.1. Endoscopic evaluation techniques for post-surgical assessment
• II.2.1.1. Endoscopic capsule
• II.5.2. Radiological studies to assess post-surgical recurrence
• II.6. Seeking consensus between the different diagnostic and follow-up options for inflammatory bowel disease. Interpretation of the results obtained