Abstract
BACKGROUND:
Crohn’s disease (CD) is a chronic inflammatory disease that can affect all segments of the gastrointestinal tract. With various phenotypes and progressive course, it can be complicated with fistulas, abscesses or stenosis. Treatment targets includes clinical remission and mucosal healing in order to avoid complicated outcomes. Double balloon enteroscopy (DBE) allows complete evaluation of the small intestine, providing diagnoses and the possibility of interventions such as biopsies, with low complication rates. Some authors suggest that involvement of the proximal small bowel may indicate worse long-term therapeutic outcomes. This study aims to correlate jejunal endoscopic findings observed in baseline DBE with the activity of CD after 10 years of follow-up.
METHODS:
Twenty paediatric refractory CD patients (2–17 years old) performed DBE by a single experienced specialist after radiological evaluation for stenosis exclusion between 2007 and 2010. After 10 years, the degree of CD activity was assessed by the Harvey-Bradshaw Index (HBI), C-Reactive Protein (CRP) serum dosage, and current therapy through collection of electronic medical records and personal communication.
RESULTS:
Sixteen 16/20 patients (80%) completed the 10 years follow up period. Two patients (2/16) changed diagnosis (1- monogenic disease, IL-10 and / or IL10R gene mutation; 1 – ulcerative colitis). Previous findings of DBE of the 14 patients corresponded to: 2 active duodenojejunal ulcers, 4 duodenojejunal scar retractions, 1 retraction and pseudopolyps in the proximal ileum, 6 hyperemia and / or edema and / or granularity of the jejunal mucosa, and 1 without alteration. After 10 years, 6/14 patients have abnormal CRP (>5 mg/L), with 3 of them having HBI between 5 and 7, 2 between 8 and 16 and 1 of 4. All of them presented previous jejunal alterations, 5/6 are currently in use of biologic and 3/6 are steroid dependent. The 2 patients who had active ulcers in baseline DBE remain steroid dependent and with higher rates of HBI activity. Eight patients (8/14) have normal CRP, all presenting HBI lower than 5. Of these, 3 are using combined therapy with immunosuppressant and biologic, 1 with biologic monotherapy, 2 with immunosuppressant, and 2 without medication.
CONCLUSION(S):
Active jejunal disease, observed through DBE, may indicate a more severe phenotype in CD after long-term follow-up, suggesting a distinct phenotype. Evaluation of the proximal small intestine should be considered in refractory paediatric CD patients or those with diagnostic uncertainty.
