P233 Management of patients with quiescent Crohn’s disease based on Capsule Endoscopy Crohn’s Disease Activity Index
T. Omori*, B. Iizuka, H. Kashiwagi, T. Hara, T. Kuriyama, A. Ito, M. Yonezawa, K. Tokushige
Tokyo Women’s Medical University, Gastroenterology, Tokyo, Japan
Crohn’s disease (CD) patients with no symptoms and negative inflammatory markers still may be at risk of relapse. Capsule endoscopy (CE) allows convenient visualisation and scoring of the mucosal condition at sites of small bowel lesions in CD patients. However, in many patients with no symptoms and CE suggesting no activity together with negative inflammatory, indications for starting treatment are unclear. This study was to understand the long-term outcomes in such patients, to determine the indications for initiating treatment for CD based on CE.
Between July 2012 and March 2015, CE was undertaken in 77 patients with CD after patency was confirmed by a patency capsule. Further, 24 patients who required treatment within 3 months after CE were excluded, and 53 were evaluated. At CE, the Capsule Endoscopy Crohn’s Disease Activity Index (CECDAI) was determined and the patients were divided into a CECDAI ≤ 3 group (n = 28) and a CECDAI ≥ 4 group (n = 25). The rationale for classification into 2 groups was as follows. A CECDAI score of 3.8 is believed to be equivalent to a Lewis score of 135; CECDAI < 3.8, and Lewis < 135 are considered normal (quiescent disease), whereas a CECDAI score of 5.8 is equivalent to a Lewis score of 790; CECDAI ≥ 5.8 and Lewis ≥ 790 indicate moderate-to-severe disease. Because the CECDAI score is calculated as an integer, a score of ≤ 3 is normal in clinical setting.
The included patients were 28 male, and 25 female, average age 40.9 ± 15.7 years. Likewise, the average duration of CD was 120 ± 92 months. In 14 patients, CD lesions were confined to the small intestinal, and 39 patients had small and large intestinal involvement. At CE, the CDAI score was 84 ± 58, albumin (Alb) = 4.3 ± 0.4 g/dl, and C-reactive protein (CRP) 0.4 ± 1.2 mg/dl. There was no significant difference between the 2 groups with respect to age, disease duration, CDAI score, or medications including corticosteroids biologics, immunomodulators, surgical history, haemoglobin, Alb, CRP. However, the Kaplan–Meier survival analysis showed a significant difference between the CECDAI ≤ 3 and the CECDAI ≥ 4 groups (p = 0.0105, log-rank test).
We found that significantly more patients with the CECDAI ≥ 4 required treatment intensification or needed to switch to an alternative treatment over the long term after CE, even when CDAI or CRP was not high at the time of CE. Based on these observations, we believe that the justification for starting aggressive therapeutic intervention in the clinical practice setting is not clear, if the patient has no symptoms. In contrast, if a patient has a CECDAI score of ≥ 4, diligent monitoring is warranted to suppress a likely CD flare up.