From the Guidelines
The next step in evaluation for this 42-year-old man with previously noted granulomatous ulceration of the ileum and multiple small bowel ulcerations on capsule endoscopy, but now normal MRI enterography and normal calprotectin, would be to perform a colonoscopy with ileoscopy and biopsies. This procedure would allow direct visualization and tissue sampling of the terminal ileum and colon to assess for active disease or healing. I would recommend obtaining multiple biopsies from the terminal ileum and any abnormal areas, as well as random biopsies from normal-appearing mucosa. Additionally, serologic testing including ASCA (anti-Saccharomyces cerevisiae antibodies) and ANCA (anti-neutrophil cytoplasmic antibodies) would help differentiate between Crohn's disease and other conditions, as suggested by the european evidence based consensus for endoscopy in inflammatory bowel disease 1. Given the discrepancy between the initial findings and follow-up studies, it's essential to rule out other causes of granulomatous disease such as tuberculosis, so interferon-gamma release assay (IGRA) testing should be performed. The normal calprotectin and MRI findings suggest possible healing or remission of the inflammatory process, but histologic confirmation is necessary since microscopic inflammation can persist despite normal imaging and biomarkers, as highlighted in the aga clinical practice guideline on the role of biomarkers for the management of ulcerative colitis 1. If colonoscopy with ileoscopy is unrevealing, consideration should be given to balloon-assisted enteroscopy to directly visualize and biopsy the previously affected small bowel segments, as supported by the acr appropriateness criteria for crohn disease 1.
Some key points to consider in this evaluation include:
- The use of biomarkers such as fecal calprotectin to monitor disease activity and guide treatment decisions, as recommended by the aga clinical practice guideline 1.
- The importance of histologic confirmation of disease activity or healing, despite normal imaging and biomarkers, as emphasized in the european evidence based consensus for endoscopy in inflammatory bowel disease 1 and the acr appropriateness criteria for crohn disease 1.
- The need to rule out other causes of granulomatous disease, such as tuberculosis, using tests like IGRA, as part of a comprehensive diagnostic approach.
From the Research
Next Steps in Evaluation
The patient's presentation of granulomatous ulceration in the ileum, along with numerous small ulcerations throughout the small bowel on capsule endoscopy, suggests a possible diagnosis of Crohn's disease 2. However, the normal MRI enterography and calprotectin levels 6 months later may indicate a remission or a mild disease course.
Diagnostic Considerations
- The presence of granulomas in the gastrointestinal tract can be caused by various factors, including infections or non-infectious immune reactions 2.
- Crohn's disease is a possible diagnosis, but the absence of severe strictures or ulceration on MRI enterography may suggest a less severe disease course 3.
- The role of MR enterography in assessing Crohn's disease activity and treatment response is well-established, and it may be useful in monitoring the patient's disease course 4, 5.
Potential Next Steps
- Consider repeating the capsule endoscopy or performing a colonoscopy with biopsy to assess the extent and severity of the disease.
- Evaluate the patient's clinical symptoms and laboratory results to determine the best course of treatment.
- If Crohn's disease is confirmed, consider using MR enterography to monitor the patient's response to treatment and adjust the treatment plan as needed 3, 5.