Abstract Background Capsule endoscopy (SBCE) and double-balloon enteroscopy (DBE) are key modalities for the evaluation of small bowel Crohn’s disease (CD), particularly when conventional ileocolonoscopy and imaging are inconclusive. SBCE offers high sensitivity for mucosal abnormalities, while DBE enables histological confirmation and therapeutic intervention but is expensive and invasive. Diagnostic yield is highly dependent on appropriate referral and pre-procedural assessment. Methods A retrospective analysis of all patients referred to a small bowel capsule service for suspected CD over a two year period was performed. Patients were identified from local capsule database. Patient demographics, referral details, SBCE and DBE reports and MDT findings were assessed. Only PillCam SB3 capsules were included for consistency. Data on prior colonoscopy, histology, faecal calprotectin, and MR enterography (MRE) were recorded. Primary outcome assessed was decision to proceed to diagnostic DBE or not. Secondary outcomes were diagnostic yields for IBD for SBCE and DBE. Contingency analyses and multivariate regression analyses were undertaken to assess covariates and their significance. Results 115 referrals of patients with suspected small bowel IBD were assessed, 108 with complete data were included. Median age was 40.5, 48% referrals were female. Primary symptoms at referral were diarrhoea, abdominal pain, anaemia/bleeding, weight loss, other. 92% had complete workup including OGD/ Colonoscopy, labwork and imaging studies prior to referral for small bowel capsule or DBE. 6 ( 5.5%) referrals went directly to DBE for therapeutic intervention or histological assessment. 90.8% proceeded to SBCE initially. The capsule to DBE conversion rate was 30.4% in this cohort. SBCE alone provided IBD diagnosis in 37% and excluded clearly in 33%. Subsequent DBE confirmed IBD diagnosis in a further 6 ( 21% of those performed) and refuted suspicion for IBD in 22 patients (79%), Primary indication for DBE was diagnostic uncertainty at SBCE. Non specific enteritis as a finding was significantly associated with referral to DBE p 0.0001. Increased age (OR = 1.04, 1.01; 1.07, p = 0.0053) and diagnostic uncertainty at SBCE (OR = 2.01.8, 3.5, p 0.001) were associated with higher rates of decision for DBE in logistic regression analysis. Conclusion SBCE provides a diagnosis for the majority of patients with suspected SBCD and DBE can be reserved for those with diagnostic uncertainty or need for therapeutic intervention or definitive histological confirmation. We propose a clinical algorithm to aid decision making for IBD clinicians and aid timely and appropriate referral to small bowel MDT services for these patients. References: 1. Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG ClinicalGuideline: Management of Crohn’s Disease in Adults. Am J Gastroenterol.2018;113(4):481-517. doi:10.1038/ajg.2018.27. 2. Lichtenstein GR, Loftus EV, Afzali A, Regueiro MD, Danese S, Sands BE, et al. ACGClinical Guideline: Management of Crohn’s Disease in Adults. Am J Gastroenterol.2025;120(6):1225-1264. doi:10.14309/ajg.0000000000003465. 3. Khan S, Dahiya DS, Jadoon AK, Kamal F, Bakalov V, Chaput E, et al. A Network Meta-Analysis of Capsule Endoscopy Versus Imaging Modalities for Diagnosing Small BowelCrohn’s Disease. J Crohns Colitis. 2025;jjaf127. doi:10.1093/ecco-jcc/jjaf127. 4. Le Berre C, Trang-Poisson C, Bourreille A. Small Bowel Capsule Endoscopy and Treat-to-Target in Crohn’s Disease: A Systematic Review. World J Gastroenterol.2019;25(31):4534-4554. doi:10.3748/wjg.v25.i31.4534. Conflict of interest: Dr. Hegarty, Cormac: No conflict of interest Sheehan, Thomas: No conflict of interest Cannaughton, Roisin: No conflict of interest Casey, Orlaith: No conflict of interest Nally, Fionn: No conflict of interest Costigan, Conor: No conflict of interest Semenov, Serhiy: No conflict of interest Shafiq, Ismail: No conflict of interest Hall, Barry: No conflict of interest Kelly, Orlaith: No conflict of interest
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