The substantial morbidity and mortality associated with Crohn's disease underlines the importance of accurate assessment at presentation, during follow-up, when investigating complications, and when evaluating the response to therapeutic interventions. Accurate methods are required to quantify the severity and extent of disease.

With the introduction of new techniques to image the small bowel, there remains uncertainty about their role for diagnosing Crohn's disease.

To assess the sensitivity and specificity of capsule endoscopy (CE), CT enterography (CTE), ileocolonoscopy, and small-bowel follow-through (SBFT) in the diagnosis of small bowel Crohn's disease.

Prospective, blinded trial.

Inflammatory bowel disease clinic at an academic medical center.

Known or suspected Crohn's disease. Exclusion criteria included known abdominal abscess and non-steroidal anti-inflammatory drug (NSAID) use. Partial small-bowel obstruction (PSBO) at CTE excluded patients from subsequent CE.

Patients underwent all 4 tests over a 4-day period.

Sensitivity, specificity, and accuracy of each test to detect active small-bowel Crohn's disease. The criterion standard was a consensus diagnosis based upon clinical presentation and all 4 studies.

Forty-one CTE examinations were performed. Seven patients (17%) had an asymptomatic PSBO. Forty patients underwent colonoscopy, 38 had SBFT studies, and 28 had CE examinations. Small-bowel Crohn's disease was active in 51%, absent in 42%, inactive in 5%, and suspicious in 2% of patients. The sensitivity of CE for detecting active small-bowel Crohn's disease was 83%, not significantly higher than CTE (83%), ileocolonoscopy (74%), or SBFT (65%). However, the specificity of CE (53%) was significantly lower than the other tests (P < .05). One patient developed a transient PSBO due to CE, but no patients had retained capsules.

Use of a consensus clinical diagnosis as the criterion standard-but this is how Crohn's disease is diagnosed in practice.

The sensitivity of CE for active small-bowel Crohn's disease was not significantly different from CTE, ileocolonoscopy, or SBFT. However, lower specificity and the need for preceding small-bowel radiography (due to the high frequency of asymptomatic PSBO) may limit the utility of CE as a first-line test for Crohn's disease.

Crohn's disease is more likely a systemic disease governed by a shift in the immune response, thus affecting the whole MALT system. Its treatment should be as conservative as possible and surgery is usually taking place after complications like indolent fistulations, stenoses, bleeding, or bowel perforation started. Standard radiological methods to check the extent of the disease are loaded either with certain radiation exposure (enteroclysis, CT) or lack standardization (ultrasound). The aim of this small study was to evaluate the worth of ultrasound-enteroclysis in detecting the extent and complications of the Crohn's disease in surgically treated patients.

Since 1997, when we started with the ultrasound-enteroclysis, 246 surgical performances were involved into our study. Out of them, 181 had conventional abdominal intestinal ultrasound as well as conventional enteroclysis within 1 week. Remaining 65 cases were diagnosed by the ultrasound-enteroclysis. Intestinal ultrasound was performed on the Ultramark 3000 HDI device with autofocussable convex 5 MHz and linear 7.5 MHz probes or nowadays ATL 5000 HDI, 7-12 MHz linear probe. No contrast enhancement was used. Enteroclysis was done with the Micropaque suspension diluted 1:1 with HP-7000 300 ml with its application rate up to 75 ml/min followed by HP-7000 solution 2000 ml, application rate of 120 ml/min. The patients with ultrasound-enteroclysis were applied HP 7000 solution only (2000 ml, rate 100ml/s) via an enteroclysis catheter. All investigations were video-recorded.

Consent with the per-operative finding was reached in 162 from 181 enteroclyses and in 169 of 181 ultrasounds. Ultrasound-enteroclysis was precise in 61 cases from 65. Among these, 60 patients had the recurrence during the treatment proved by clinical and laboratory results. This re-activation was clearly revealed in 38 from 43 cases by enteroclysis, 41 from 43 by US and in 16 from 17 by ultrasound-enteroclysis. From 30 patients that developed acute complication non-responding to the conservative therapy (abscesses, fistulas and intestinal obstructions) there were 18 from 20 accurately diagnosed by enteroclysis, only 12 from 20 by US and 9 from 10 by US-enteroclysis. The differences were either statistically non-significant or there were too small numbers to give sensible statistical results, but low sensitivity of ultrasound in complications (p=0.05).

US-enteroclysis seems to became the standard examination of patients with Crohn's disease mainly in those with unclear conventional ultrasound. The most important fact is that this examination significantly decreases the radiation load when maintaining high sensitivity. This is very important namely in patients with Crohn's disease that require life-long observation and repeated examinations. This examination is much more easy to standardize than the conventional US.

Capsule endoscopy (CE) allows visualization of the mucosa of the entire small bowel and is therefore a potentially important tool in the evaluation of patients with known or suspected Crohn's disease (CD). However, small bowel strictures, which are not uncommon in Crohn's, are considered to be a contraindication to CE for fear of capsule retention. Our goal was to determine the risk of capsule retention in patients with suspected or known CD.

We retrospectively reviewed the records of 983 CE cases performed at three private gastroenterology practices between December 2000 and December 2003, and selected those with suspected or proven Crohn's.

A total of 102 cases were identified in which CE was used in patients with suspected (N = 64) or known (N = 38) CD. Only one of 64 patients (1.6%) with suspected CD had a retained capsule. However, in five of 38 (13%) patients with known Crohn's, the capsule was retained proximal to a stricture. Of the five cases of retained capsules, three strictures were previously unknown. In four cases, the obstructing lesions were resected without complications, leading to complete resolution of the patient's underlying symptoms. One patient chose not to undergo surgery and has remained without an episode of small bowel obstruction for over 38 months.

Capsule retention occurred in 13% (95% CI 5.6%-28%) of patients with known CD, but only in 1.6% (95% CI 0.2%-10%) with suspected Crohn's. A retained capsule may indicate unsuspected strictures in Crohn's that may require an unexpected, but therapeutic, surgical intervention. Patients and physicians should be aware of these potential risks when using CE in CD.

The recently introduced wireless M2A capsule video endoscopy (CVE) has been demonstrated to be superior to barium follow-through and enteroscopy in diagnosing patients with occult blood loss and iron-deficiency anaemia.

To further investigate CVE in comparison to barium follow-through and entero-computerized tomography (CT) in establishing the diagnosis of patients with suspected Crohn's disease.

The study was conducted in one academic hospital. Twenty patients with recurrent abdominal pain and/or weight loss or chronic diarrhoea underwent barium follow-through as their initial examination, followed by CVE (if there was no stricture) and entero-CT. The radiologist that performed the barium follow-through and entero-CT was blinded to the results of the CVE. A blinded reader who was unaware of the study objective diagnosed the results of the CVE. In most cases in which there was a discrepancy between examinations, colonoscopy and ileoscopy were performed. For each patient, the diagnosis and disease extent were recorded.

Twenty patients (13 males, 7 females; mean age 31 years, range 20-57) were included in the study. Ninety-five per cent of the patients had abdominal pain, 75% had diarrhoea, and 65% had weight loss. The mean haemoglobin level of the group was 13.1 g% (range 10-15.5). Only 13 patients underwent entero-CT.CVE confirmed the diagnosis of Crohn's disease that was suspected by alternative methods in six of the 20 patients. CVE made the diagnosis of Crohn's disease in six patients that had normal barium follow-through or entero-CT. CVE ruled out a diagnosis of Crohn's disease suspected by other modalities in three patients. CVE extended the involvement of Crohn's disease in three of the patients, and established new diagnoses in two patients.

CVE established new diagnoses, confirmed existing diagnoses, enlarged the extent of the disease, and ruled out the suspicion of Crohn's disease in 70% of the patients. Barium follow-through established diagnoses, measured the extent of the disease, and ruled out the suspicion of Crohn's disease in 37% of the patients. The capsule detected all of the lesions diagnosed by barium follow-through and entero-CT. CVE detected additional lesions that were not detected by other modalities in 47% of cases and ruled out lesions that were detected by other modalities in 16% of cases (P < 0.05).

CVE is a superior and more sensitive procedure than barium follow-through and entero-CT in establishing the diagnosis and estimating the extent of Crohn's disease.

This article has reviewed the imaging features that correspond to and support the classification of patients into clinical subtypes of Crohn's disease. One study showed that radiologic features on barium studies closely correlated with the Crohn's Disease Activity Index, and another study indicated that CT findings changed patient management in up to 29% of cases. Knowledge of the location, severity, and presence of complications assist in providing patients with appropriate treatment options. Reports of radiologic studies in Crohn's disease should include the presence or absence of imaging features that support these different subtypes. An additional advantage of the use of a reproducible imaging classification that emphasizes morphologic features would be improved comparison of the results of different investigators and treatment protocols. Whatever method of radiologic investigation is employed, it should be targeted to answer questions relevant to patient management. The imaging modalities used should be able to classify the small bowel Crohn's subtypes and should be reflected in the radiologists' reports.

During the last few decades introducing many of new radiologic methods, diagnostic conditions and facilities of Crohn's disease has became markedly improved. Appropriate using of these technics definitely modifies the management of patients with known or suspected Crohn's disease serving reliable information about extent, severity and possible complications of disease. Enteroclysis and Computed tomography are the two major and basic methods to disclose or confirme diagnosis of Crohn's disease, obtain appropriate inforination about disease either with mucosal, transmural or extraintestinal manifestation.

We evaluated 281 patients who were referred in our institution under suspition of Crohn's disease. Enteroclysis and abdominal spiral CT in all cases were carried out usually within 1 week. The 172 patients underwent abdominal spiral CT as the primary examination to evaluate diagnostic value of spiral CT in this entity, while 109 patiens had enteroclysis followed by abdominal CT. In 11 cases we also perforined CT enteroclysis with administration of 0.5% methylcellulose solution thorough nasojejunal tube controlled by electric motor driven contrast pump. Results were compared with final clinical, pathological or surgical data were available.

From the 281 patients eventually 74 proved Crohn's disease; sensitivity and specificity of enteroclysis proved to be 96 and 98%, while spiral CT sensitivity and specificity was 94 and 95%, respectively. Enteroclysis was superior to the spiral CT in demonstration of early lesions and functional disorders, while spiral CT proved to be essential in evaluation of transmural and extraintestinal complications.

Regarding enteroclysis and spiral CT as complementary methods, they provide excellent results in diagnosis of Crohn's disease.

In a retrospective study the radiological reports of small bowel enema (enteroclysis) examinations of 1465 patients were reviewed and compared with the subsequent clinical outcome, and where possible with findings at laparotomy. A sensitivity of 93.1% and a specificity of 96.9% was found, based on whether the small intestine was reported as normal or an abnormality was diagnosed to account for the patient's clinical presentation. The correct specific diagnosis was made in 67.5% of the examinations that were considered abnormal. We believe that these figures support the use of small bowel enema as the routine barium examination for suspected disorders of the small intestine.

A study has been made of 93 Japanese patients with Crohn's disease who had not undergone bowel resection at the time of diagnosis during the years 1969 to 1983. Ninety had longitudinal ulcers or a cobblestone appearance or both of the small intestine or colon or both on double contrast barium examination. The incidence of longitudinal ulcers in the small intestine was significantly higher than in the colon (P less than 0.001). Conversely the incidence of cobblestoning was higher in the colon than in the small intestine (P = 0.065). In patients with longitudinal ulceration, there was significantly lower Crohn's disease activity index (CDAI), ESR, and C-reactive protein. Patients with cobblestoning had a significantly higher CDAI, ESR and C-reactive protein, and significantly lower values of albumin, cholesterol in serum, serum iron, haemoglobin, and relative body weight. Our findings indicate that cobblestoning closely correlates with the disease activity of Crohn's disease, and that longitudinal ulceration has a negative correlation. Moreover, our results suggest that the high incidence of cobblestoning and low incidence of longitudinal ulcers in the colon and the reverse in the small intestine reflects the fact that colonic involvement renders the disease more severe than small intestine involvement only.

The radiological findings, using a single-contrast barium infusion technique, are described in a series of 13 patients with chronic radiation enteritis. The signs include evidence of submucosal thickening, single or multiple stenoses, adhesions and sinus or fistula formation. A combination of these signs characterises the condition. This technique is particularly suited to the investigation of radiation enteritis because of its ability to distend maximally the small intestine. A cause, stenosis and/or adhesions, was demonstrated in the eight of the 13 patients presenting with intermittent small-intestinal obstruction. Three patients had diarrhoea as their predominant complaint and a fistula was demonstrated in two.

A technique for performing small bowel enemas in children is described in detail and the results of using this technique reported. Minor modifications are necessary to the technique commonly used in adults; a softer tube is used and sedation given early and generously. It is stressed that the radiologist must control the sedation as well as the radiology.