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Bojórquez et al. Mini-invasive Surg 2023;7:8 https://dx.doi.org/10.20517/2574-1225.2022.65 Page 3 of 7

[2]
relapse is suspected or when new symptoms arise .

NON-INVASIVE DETECTION OF CROHN’S DISEASE POSTOPERATIVE RECURRENCE
WHY? Surgical resection and disease recurrence are common in many CD patients. Recurrence can occur
at the anastomosis or in a proximal segment. Within three years after an ileocolectomy, up to 100% of
patients may suffer from endoscopic recurrence without treatment, with at least 65% recurrence within the
first year, according to Rutgeerts et al. [13]

Although ileocolonoscopy is recommended in the first 12 months after ileocolectomy , CD recurrence in
the small bowel can also occur after total proctocolectomy and ileostomy, with a 23.5% 10-year median
cumulative rate . Capsule endoscopy may aid in early detection of endoscopic recurrence as there is a
[14]
[15]
correlation between Rutgeerts score evaluated by ileocolonoscopy and capsule endoscopy findings . To
detect endoscopic recurrence before symptoms arise and improve outcomes through optimized biologic
therapy, Shiga et al. recommend postoperative repeated SBCE, starting within three months from
surgery . Moreover, SBCE is recommended in the postoperative setting due to its lower morbidity and
[16]
higher sensitivity, especially in detecting proximal SB activity.

ALTERNATIVES TO CAPSULE ENDOSCOPY
Local expertise and availability should guide study selection in both CD diagnosis and monitoring. Cross-
sectional imaging techniques are alternatives to endoscopy for evaluating disease activity and monitoring.
Growing evidence suggests MRE and IUS can be used as first-line investigations for diagnosing and
[17]
monitoring CD . Since CD monitoring strategies demand repeated evaluation of disease activity, patients
may prefer cross-sectional imaging over endoscopy in the long term due to its non-invasiveness .
[18]
As previously mentioned, SBCE, MRE and IUS have similar diagnostic yields for detection of SB
activity [2,3,19] . Activity scoring systems are available for both MRE and IUS. MRE activity scores have been
demonstrated to have a high correlation with endoscopic indexes like the Rutgeerts score, while few IUS
scores have been validated against MRE or endoscopy scores [17,18] .

One advantage of cross-sectional imaging is the ability to evaluate transmural disease. If there is a clinical
suspicion of a stricturing component, current guidelines recommend cross-sectional imaging over SBCE.
MRE should be the first choice to evaluate transmural disease and its penetrating complications [1,5,20] .
Additionally, cross-sectional imaging is helpful for monitoring. MRE can identify disease activity well by
measuring bowel wall thickness and T2 signal and classify therapeutic response into four categories:
transmural remission, response, stable or progression. Likewise, IUS offers a rapid, on-site evaluation of
treatment response, which can be determined as soon as 4 weeks after treatment initiation in CD .
[18]
Moreover, the terminal ileum can have active inflammation confined to intramural portions with an
overlying normal mucosa, which would not be detectable by endoscopy. Some studies have concluded that
cross-sectional imaging findings predict clinical outcomes and disease progression better. Therefore,
transmural response has been proposed as a better therapeutic target than endoscopic healing [1,17,18,20] .

Conversely, MRE performs poorly in early recognition of disease because of the minimal mucosal defect of
[7]
aphthoid ulcerations . Hence, SBCE is recommended in patients with a strong suspicion of CD and non-
diagnostic radiological tests (IUS and/or MRE) to exclude SB involvement . There is mounting evidence
[2]
that performing SBCE in these patients can influence management and prognosis. Therefore, we should
work to harmonize the findings and not consider these studies as contenders [21,22] . SBCE and cross-sectional
imaging should be considered complementary explorations in the CD evaluation.