Double balloon or double jobbing? Diagnostic yield of Small Bowel Capsule Endoscopy and Double Balloon Enteroscopy for Small Bowel Crohn's disease

Aims Small Bowel Capsule Endoscopy (SBCE) is a valuable tool in visualizing the small intestines. Paired with Double Balloon Enteroscopy (DBE), we can now obtain histological evidence to investigate small bowel Crohn’s disease. We assessed diagnostic yield using both these investigative modalities.

Methods We performed a retrospective analysis from March 2021 to September 2024 of patients referred to our small bowel capsule service. A patient list was generated from our local capsule database for suspected Crohn’s disease. PillCam SB3 was the only capsule included in this study for consistency purposes. There was also only one reporting gastroenterologist. Previous colonoscopy, histology, faecal calprotectin and MR enterography (MRE) were also analysed. I have performed linear regression statistical analysis of these variables.

Results 94 patients included over a 3-year period, 50% were female (p=0.81 therefore no significant correlation of female sex to capsule findings in keeping with Crohn’s disease) with a median of 44 years ranging from 16-80. All referrals were for patients who did not have a diagnosis of Crohn’s prior to their capsule endoscopy. 99% patients had a complete study with only one patient retaining the capsule in the stomach. 46 had Colonoscopy, 26 had raised faecal calprotectin (median 160 ranging from 5->6000) and 8 had an abnormal MRE before referral. These 8 abnormal MRE findings included, 5 reported as mural thickening of small bowel, one of a proximal jejunal stricture, one of inflammation at the terminal ileum and the last reported as active small bowel disease and distal terminal ileitis. A raised faecal calprotectin was not statistically significant for a capsule finding in keeping with Crohn’s disease with p=0.357 however, an abnormal MRE report was p=0.034. 64.8% of SBCE performed had an abnormal report, 35.1% had a capsule findings in keeping with a Crohn’s diagnosis i.e 54% of abnormal findings on capsule were indicative of Crohn’s disease. Further investigations included repeat SBCE (10.7%), repeat ileocolonoscopy (1.96%) or DBE (RDBE 16.6% and ADBE 10.7%). Patients underwent repeat capsule studies mostly due to assess healing of ulcers/erosions alongside, nonspecific enteritis to clarify significance and one case of a retained capsule in stomach and one case of recurrent abdominal pain after a DBE [1] [2] [3].

Conclusions Small Bowel Capsule and Double Balloon Enteroscopy are very important modalities in diagnosing and treating small bowel pathologies. From this audit it was found to have good diagnostic yield for the diagnosis of small bowel Crohn’s with over half of abnormal capsule reports leading to a Crohn’s diagnosis. MRE has shown a significant precursor to Capsule endoscopy and I would imagine intestinal ultrasound in the near future will play a similar role. To further this work, I will assess the specific location of small bowel disease and correlate this to faecal calprotectin levels.

Publication History

Article published online:
27 March 2025

• References

• 1 Niemenmaa H., Mäkelä T., Jussila A., Krekelä I., Voutilainen M., Björknäs H., Hirvioja A., Kaukinen K., Collin P.. The diagnostic value of video capsule endoscopy European Journal of Internal Medicine [online] 2010; 21 (5) pp 383-385 doi:10.1016/j.ejim.2010.06.014.
• 2 Avni-Biron I, Toth E, Ollech JE, Nemeth A, Johansson GW, Schweinstein H, Margalit RY, Kopylov U, Dotan I, Yanai H. The Role of Small-Bowel Capsule Endoscopy in the Diagnostic Algorithm of Complicated Perianal Disease Diagnostics [online] 2024; 14 (16) pp 1733-1733 doi:10.3390/diagnostics14161733.
• 3 "The Role of Small-Bowel Capsule Endoscopy in the Diagnostic Algorithm of Complicated Perianal Disease". Irit Avni Biron