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

BACKGROUND: 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. METHODS: 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. RESULTS: 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%. CONCLUSIONS: 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.