Long-term outcomes of patients with negative small bowel video capsule endoscopy for Crohn's disease: A cohort study

In the diagnostic algorithm of Crohn's disease (CD), video capsule endoscopy (VCE) is used as a subsequent investigation when initial assessments are inconclusive (ileocolonoscopy and computed tomography/magnetic resonance enterography). The long-term clinical significance of a negative VCE remains uncertain. Therefore, we evaluated long-term clinical outcomes in patients with suspected CD and inconclusive standard investigation.

We conducted a retrospective cohort study of adults with inconclusive standard investigation for suspected CD who were referred for VCE at a tertiary inflammatory bowel diseases center between 2008 and 2017. VCE studies were scored using the Lewis score. Patients with a Lewis score <135 were defined as "negative VCE." Patients with negative VCE were followed for subsequent CD or alternative diagnoses. Final CD diagnosis was verified by review of electronic clinical charts.

Among 615 consecutive patients (median age 36 years; 57.5% female), 192 (31.2%) were identified with a positive VCE suggestive of small bowel CD. Overall, 18 (4.3%) of 423 patients with a negative VCE had a subsequent diagnosis of CD over a median follow-up of 11 years (interquartile range: 10-13 years; 4665 patient-years); median time to diagnosis was 1.5 years (interquartile range: 1-3 years). An alternative diagnosis was established in ∼70% of patients with negative VCE (mostly functional disorders and noninflammatory conditions). The negative predictive value for a negative VCE to exclude CD was 95.7%.

A negative VCE confers a very low likelihood of subsequent CD diagnosis in patients with suspected CD after nondiagnostic standard evaluation. Diagnostic efforts should instead focus on functional evaluation and dietary intervention.