Reclassifying inflammatory bowel disease with capsule endoscopy in children

Joshi, Shruti Shree; Vyas, Arpita Kalla; Vyas, Dinesh; Kalla, Rahul

doi:10.1016/j.jped.2013.07.002

LETTERS TO THE EDITOR

^IMBBS, Department of Medicine, Maidstone General Hospital, Maidstone, Kent, United Kingdom

^IIMBcHB MD, Department of Pediatrics and Human Development, Michigan State University, East Lansing, United States

^IIIMD MS FICS, Department of Surgery, Nanomedical OncoSepsis Lab, Institute of International Health, College of Human Medicine, Michigan State University, East Lansing, United States

^IVMBcHB MRCP, Gastroenterology & Liver Unit, Manchester Royal Infirmary, Oxford Road, Manchester, United Kingdom

We read with great interest the article by Ouahed et al.¹on the role of wireless capsule endoscopy in reclassifying inflammatory bowel disease in children. It was the first prospective study concerning reclassification of inflammatory bowel disease unclassified (IBDU) in the pediatric population. It is an addition to the growing evidence of the role of capsule endoscopy (CE) in this subtype of inflammatory bowel disease, both in pediatric and adult populations.^1-6

There is currently no validated scoring system for the diagnosis of small bowel Crohn's disease (SBCD). Most studies use the consensus criterion of three or more ulcers as predictive of SBCD in adults.⁷There is no evidence whether this criterion can safely predict SBCD in the pediatric population, bearing in mind that mucosal breaks can occur in healthy adults,⁸and the type and severity of mucosal changes in healthy children is yet to be determined. In addition, and as mentioned by the authors, non-steroidal anti-inflammatory drugs (NSAIDs) can mimic SBCD at capsule endoscopy; therefore, this data should have been provided by the authors. This does have a bearing on the sensitivity and specificity of that study.

Studies within adult populations have shown a disparity in the management of post-CE outcomes among symptomatic^2,5,6versus asymptomatic³IBDU patients. Therefore, it would be worth knowing whether the patients were symptomatic at the time of CE. In addition, although the authors mention a change in the management of three patients, it would be useful to know the details of the post-CE change in medical therapy to truly assess the impact of a positive or negative CE. It would also strengthen the argument for performing a cost-effective test in the pediatric population.

We agree with the authors that CE is a novel tool in reclassifying IBDU patients, compared to standard small bowel investigations. It must be said however, that CE findings with no histological confirmation would need to be interpreted with caution and with regard to clinical context, as a false positive could result in intensified therapy and cause psychological side effects.⁹

References

1. Ouahed J, Shagrani M, Sant'Anna A. Role of wireless capsule endoscopy in reclassifying inflammatory bowel disease in children. J Pediatr (Rio J). 2013;89:204-9.
2. Kalla R, McAlindon ME, Drew K, Sidhu R. Clinical utility of capsule endoscopy in patients with Crohn's disease and inflammatory bowel disease unclassified. Eur J Gastroenterol Hepatol. 2013;25:706-13.
3. Lopes S, Figueiredo P, Portela F, Freire P, Almeida N, Lérias C, et al. Capsule endoscopy in inflammatory bowel disease type unclassified and indeterminate colitis serologically negative. Inflamm Bowel Dis. 2010;16:1663-8.
4. Mehdizadeh S, Chen GC, Barkodar L, Enayati PJ, Pirouz S, Yadegari M, et al. Capsule endoscopy in patients with Crohn's disease: diagnostic yield and safety. Gastrointest Endosc. 2010;71:121-7.
5. Maunoury V, Savoye G, Bourreille A, Bouhnik Y, Jarry M, Sacher-Huvelin S, et al. Value of wireless capsule endoscopy in patients with indeterminate colitis (inflammatory bowel disease type unclassified). Inflamm Bowel Dis. 2007;13:152-5.
6. Mow WS, Lo SK, Targan SR, Dubinsky MC, Treyzon L, Abreu-Martin MT, et al. Initial experience with wireless capsule enteroscopy in the diagnosis and management of inflammatory bowel disease. Clin Gastroenterol Hepatol. 2004;2:31-40.
7. Bourreille A, Ignjatovic A, Aabakken L, Loftus EV Jr, Eliakim R, Pennazio M, et al. Role of small-bowel endoscopy in the management of patients with inflammatory bowel disease: an international OMED-ECCO consensus. Endoscopy. 2009;41: 618-37.
8. Goldstein JL, Eisen GM, Lewis B, Gralnek IM, Zlotnick S, Fort JG, et al. Video capsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus omeprazole, and placebo. Clin Gastroenterol Hepatol. 2005;3:133-41.
9. Gailhoustet L, Goulet O, Cachin N, Schmitz J. Study of psychological repercussions of 2 modes of treatment of adolescents with Crohn's disease. Arch Pediatr. 2002;9:110-6.