Background/Purpose:

Inflammatory bowel disease (IBD) is clinically associated with spondylarthropathies (SpA) in 5-15% of cases. Protocol colonoscopic assessment demonstrated asymptomatic inflammation characteristic of Crohn’s disease in up to 1/3 of SpA patients. Videocapsule endoscopy (VCE) is a superior diagnostic tool to detect small bowel (SB) mucosal pathology. However, it has been infrequently used to evaluate bowel inflammation in SpA. This study compared the accuracy of VCE to standard ileocolonoscopy (IC) for the detection of inflammatory bowel lesions in patients with SpA, and to describe the clinical and laboratory predictors of SB inflammation in this cohort. 

Methods:

Prospective cross-sectional study, involving consenting patients   > age 18 with an established diagnosis of SpA. Exclusion criteria included any NSAID use in the previous month or treatment with infliximab, adalimumab or certolizumab. All patients first were evaluated by VCE, followed by IC with biopsies.  SB inflammation was quantified using the Lewis Score (LS). Significant inflammation was defined as LS ≥350. Screening tests evaluated included fecal calprotectin (FCP, Buhlmann Laboratories, Basel, Switzerland);  levels ≥ 100 ug/g ‎ considered positive. A panel of serologic, inflammatory and genetic testing (IBD SGI Diagnostic™) was performed (Prometheus Labs, San Diego, CA). In a subgroup of patients, NOD2 mutations were assessed using a Sequenom array. Results were correlated with the presence of significant inflammation on VCE.

Results: 

63 patients (54% female, mean age 42±13 years) were recruited; 2 patients refused IC and were disqualified. GI symptoms (chronic diarrhea/abdominal pain/weight loss) were present in 57%. FCP levels were elevated in 47% of patients. Significant SB inflammation was demonstrated by VCE in 25/61 (41%) of patients vs 8/61 (13.1%) by IC (p=0.036). All positive ileal and colonic biopsies were consistent with Crohn’s disease. Elevated FCP levels significantly correlated with mucosal inflammation on VCE (r² =0.59, p=0.0001, sensitivity 70.6%, specificity 86.6%). Correlation was not observed with the presence of GI symptoms or an elevated CRP. There was no significant correlation between SGI and VCE (r² =0.1, p=0.4, sensitivity 26.3%, specificity 82.3%). None of the individual components of SGI was correlated with significant inflammation on VCE. The prevalence of NOD2 mutations was higher in patients with significant SB inflammation (27% vs 11%), however this difference did not reach statistical significance (p=0.22).

Conclusion:

Small bowel lesions consistent with Crohn’s disease are more common in patients with SpA than generally acknowledged. VCE is superior to IC in detecting CD in patients with known SpA. Fecal calprotectin levels were significantly correlated with VCE results, while presence of GI symptoms, CRP and SGI results were poor predictors of small bowel inflammation in this patient cohort.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/uncovering-crohns-disease-in-patients-with-spondyloarthropathies-using-videocapsule-endoscopy/