**3.1 Treatment of intestinal strictures**

Strictures in CD develop during the course of the disease or as the presenting feature and are believed to result from partial healing and localized fibrosis. In addition, almost one-third of CD patients develop an anastomotic stricture after ileocecal resection/right hemicolectomy [40]. As a progressive disease, anastomotic strictures will be more likely over time.

Immunomodulators and biologic agents have been widely used for the treatment of CD, however endoscopic dilatation is a preferred technique for the management of symptomatic and mild to moderate stenosing disease [41]. Indeed, medical therapy for stricture management is limited due to fibrotic nature. Endoscopic dilatation may prevent or delay the need for surgical resection or strictureplasty. Moreover, endoscopic balloon dilation should be performed to access the mucosa proximal to strictures and evaluate disease activity, that otherwise may be missed if we only relied on symptoms or biochemical markers [42]. Thus, it can provide adequate endoscopic therapy and adjust or optimize medical therapy.

Endoscopic balloon dilation may be used in Crohn's strictures of the gastric outlet, duodenum, colon, ileocolonic anastomosis and of the small bowel, if accessible [43]. It is performed using a through-the-scope balloon catheter, which is a simple and safe procedure (**Figure 4**). The dilation procedure is performed with monitoring of the pressure of the inflated balloon using a dilator with or without X-ray guidance. When performing endoscopic balloon dilation, forcible dilation to achieve a larger dilation diameter or pressure is not recommended, as it could lead to intestinal perforation. The length of the balloons for inflation is about 5 cm; therefore, stenoses longer than 5 cm are considered unsuitable for endoscopic balloon dilation. Moreover, intestinal strictures with deep ulcers and fistulous complications are contraindications for endoscopic dilatation. In case of long or inflammatory strictures, balloon dilation may significantly increase the risk of perforation [44]. Hence, inflammatory and ulcerative strictures should be primarily treated with medical therapy.

Over the last years, there is increasing evidence for endoscopic balloon dilation as a safe and minimally invasive effective method for the treatment of stricturing disease. In a retrospective single tertiary center study, Lopes et al. evaluated the long-term efficacy and safety of endoscopic balloon dilation in ileocolonic

#### **Figure 4.**

*A segment of short stenosis is delineated using injection of contrast via a catheter (A). A guide wire is inserted through the stenosis and a balloon is then advanced over the wire and carefully inflated (B).*

strictures. The authors reported a technical success rate of 97.7% to anastomotic strictures and similar to non-anastomotic strictures (100%) without major adverse events (major bleeding and perforation) [40]. Endoscopic dilatation using balloonassisted enteroscopy for small bowel strictures is almost the same as for ileocolonic strictures in terms of procedure and technique. However, there are some technical difficulties. In fact, it is not easy to stabilize the tip of the scope and to maintain a good visual field because of the limited space available, severe angulation, motility and adhesion in the small intestine. Nevertheless, the reported technical success rate is over 85% with a perforation rate of 1% [45, 46].

A key concern of endoscopic dilatation is the long-term outcome. Indeed, a recent study showed that 63% of patients with anastomotic strictures and 41% of those with non-anastomotic strictures required additional dilation over a 4.4 year period [40]. However, Sunada et al. reported that the surgery-free rate in 321 patients with CD who underwent endoscopic dilatation for small intestinal strictures was 87% and 78% at 1 and 3 years, respectively [47]. Similarly, a systematic review assessed the role of device-assisted enteroscopy in 581 small bowel dilatations, showing an 80% long-term success rate without the need for surgery during follow-up (2.5 years per patient) [48].

In conclusion, endoscopic balloon dilation is a feasible, simple, effective and safe procedure and an appropriate option for either delaying or preventing surgery, with the possibility of being repeated as needed.

To have a persistent effect over time and avoid the high risk of recurrence, a self-expanding metallic stent has been proposed [49]. Stenting appeared to be an effective technique in treating symptomatic CD intestinal strictures, however the procedure was associated with a high rate of spontaneous migrations and complications. More recently, an anti-migration, removable and shaped self-expandable metal stent is available. Attar et al. performed a real-life study to describe shortand long-term results of the removable anti-migration stent [50]. The authors showed that it was safe and effective in about half of patients and had an extremely low migration rate, with no perforation reported. In addition, the high success rate was close to that obtained with endoscopic balloon dilation, but without complications. Taking this into account, the placement of a transient metallic stent is a new minimally invasive alternative to the management of refractory anastomotic stricture of less than 5 cm, before considering a new surgery. The use of biodegradable instead of metal stents was recently evaluated in intestinal and colonic CD strictures. Although it was technically feasible, premature stent failure occurred in all of the patients, as well as side effects such as mucosal overgrowth and stent collapse [51].

#### **3.2 Removal of impacted capsules**

One problem of video capsule endoscopy in patients with suspected or known CD is the risk of impaction due to previously undiagnosed stenoses. One effort to overcome this difficulty was the development of the patency capsule. However, the successful passage of the patency capsule does not absolutely guarantee that intestinal obstruction will not occur during the passage of the video capsule. Similarly, some stenoses may not be detected by prior radiographic methods. Therefore, capsule impaction can occur.

A retained capsule, in general, does not cause obstruction. In fact, the capsule can remain in the small bowel for several months without causing symptoms. Thus, unless malignancy is strongly suspected, conservative or pharmaceutical intervention, namely with corticosteroids, are justified therapeutic options in the majority of cases [52].

**37**

intervention [59].

*Endoscopy in Small Bowel Crohn's Disease DOI: http://dx.doi.org/10.5772/intechopen.95925*

**3.3 Treatment of bleeding lesions**

rebleeding, such as anti-TNF agents.

reports [54, 55].

gastrointestinal source.

When patients develop obstructive symptoms, they may have to undergo device-assisted enteroscopy or surgery. Push-and-pull enteroscopy using the double-balloon technique has proven to be extremely effective (90–100% of cases) and is considered the method of choice [53]. Surgery is an alternative procedure for removing impacted capsules, especially in those cases in which investigations unequivocally suggest the presence of neoplastic disease. The surgical intervention allows the removal of both the capsule and the pathology that caused capsule retention. In addition, intra-operative enteroscopy can be a useful tool to establish intra-luminal pathology like ulceration as a cause of retained endoscopic capsule. Besides some cases of acute intestinal obstruction, there are only a few more complications reported in the literature due to a retained capsule. In fact, bowel perforation and capsule disintegration have already been reported, but only in case

CD may be associated with mild gastrointestinal bleeding while major hemorrhage is a rare complication. In addition, a definitive bleeding site is not identified in most patients. In fact, hemorrhage is frequently attributed to diffuse areas of active inflammation [56]. The majority of bleeds originate from the ileum and colon and only a small number of episodes have been attributed to a jejunal or upper

Initial management of major hemorrhage should always include primary resuscitation, as in any individual with a significant gastrointestinal bleed [57]. Once a patient is stabilized, diagnostic maneuvers are of primary importance. The site of bleeding can be identified by endoscopy, angiography or labeled red blood cell scans. However, clinicians should be aware that identifying a precise source of

In the context of CD, urgent device-assisted enteroscopy for large-volume bleeding should be performed via the retrograde route, given the propensity of these conditions to involve the distal small bowel [52]. When it is identified, the source of bleeding is more commonly described as a deep ulcer eroding into a blood vessel and therapy may be attempted [56]. Endoscopy therapy includes thermocoagulation alone or a combination of epinephrine injection and bipolar coagulation [58]. Application of hemoclips may be compromised in the presence of inflamed and friable mucosa. On rare occasions, a large pseudopolyp in the ileum or colon has been identified as the source of bleeding; polypectomy should be performed in these cases. Although endoscopic therapy can stop acute bleeding, it does not promote mucosal healing and therefore cannot prevent rebleeding. In fact, the risk of rebleeding associated with endoscopic hemostasis is about 50% [56]. Thus, therapies that can induce and maintain mucosal healing are necessary to prevent

Intraoperative enteroscopy may be the most reliable method to achieve a complete small bowel evaluation. It involves evaluation of the small bowel at laparotomy and may be performed orally, rectally or via an enterotomy. Upper endoscopes, colonoscopes, push enteroscopes and balloon-assisted scopes have all been used. Although it is highly invasive and associated with major complications, it may help in the identification of the bleeding source and in planning the optimal therapeutic

When CD is complicated by obscure bleeding, video capsule endoscopy and device-assisted endoscopy may identify and treat the bleeding source beyond the reach of standard endoscopes [1]. In fact, video capsule endoscopy has a fundamental role in diagnosing obscure gastrointestinal bleeding in patients with CD. It

bleeding is difficult and salvage surgery may be necessary.

*Endoscopy in Small Bowel Crohn's Disease DOI: http://dx.doi.org/10.5772/intechopen.95925*

*Endoscopy in Small Bowel Diseases*

strictures. The authors reported a technical success rate of 97.7% to anastomotic strictures and similar to non-anastomotic strictures (100%) without major adverse events (major bleeding and perforation) [40]. Endoscopic dilatation using balloonassisted enteroscopy for small bowel strictures is almost the same as for ileocolonic strictures in terms of procedure and technique. However, there are some technical difficulties. In fact, it is not easy to stabilize the tip of the scope and to maintain a good visual field because of the limited space available, severe angulation, motility and adhesion in the small intestine. Nevertheless, the reported technical success

A key concern of endoscopic dilatation is the long-term outcome. Indeed, a recent study showed that 63% of patients with anastomotic strictures and 41% of those with non-anastomotic strictures required additional dilation over a 4.4 year period [40]. However, Sunada et al. reported that the surgery-free rate in 321 patients with CD who underwent endoscopic dilatation for small intestinal strictures was 87% and 78% at 1 and 3 years, respectively [47]. Similarly, a systematic review assessed the role of device-assisted enteroscopy in 581 small bowel dilatations, showing an 80% long-term success rate without the need for surgery during

In conclusion, endoscopic balloon dilation is a feasible, simple, effective and safe procedure and an appropriate option for either delaying or preventing surgery, with

To have a persistent effect over time and avoid the high risk of recurrence, a self-expanding metallic stent has been proposed [49]. Stenting appeared to be an effective technique in treating symptomatic CD intestinal strictures, however the procedure was associated with a high rate of spontaneous migrations and complications. More recently, an anti-migration, removable and shaped self-expandable metal stent is available. Attar et al. performed a real-life study to describe shortand long-term results of the removable anti-migration stent [50]. The authors showed that it was safe and effective in about half of patients and had an extremely low migration rate, with no perforation reported. In addition, the high success rate was close to that obtained with endoscopic balloon dilation, but without complications. Taking this into account, the placement of a transient metallic stent is a new minimally invasive alternative to the management of refractory anastomotic stricture of less than 5 cm, before considering a new surgery. The use of biodegradable instead of metal stents was recently evaluated in intestinal and colonic CD strictures. Although it was technically feasible, premature stent failure occurred in all of the patients, as well as side effects such as mucosal overgrowth and stent

One problem of video capsule endoscopy in patients with suspected or known CD is the risk of impaction due to previously undiagnosed stenoses. One effort to overcome this difficulty was the development of the patency capsule. However, the successful passage of the patency capsule does not absolutely guarantee that intestinal obstruction will not occur during the passage of the video capsule. Similarly, some stenoses may not be detected by prior radiographic methods. Therefore,

A retained capsule, in general, does not cause obstruction. In fact, the capsule can remain in the small bowel for several months without causing symptoms. Thus, unless malignancy is strongly suspected, conservative or pharmaceutical intervention, namely with corticosteroids, are justified therapeutic options in the majority

rate is over 85% with a perforation rate of 1% [45, 46].

follow-up (2.5 years per patient) [48].

the possibility of being repeated as needed.

**36**

of cases [52].

collapse [51].

**3.2 Removal of impacted capsules**

capsule impaction can occur.

When patients develop obstructive symptoms, they may have to undergo device-assisted enteroscopy or surgery. Push-and-pull enteroscopy using the double-balloon technique has proven to be extremely effective (90–100% of cases) and is considered the method of choice [53]. Surgery is an alternative procedure for removing impacted capsules, especially in those cases in which investigations unequivocally suggest the presence of neoplastic disease. The surgical intervention allows the removal of both the capsule and the pathology that caused capsule retention. In addition, intra-operative enteroscopy can be a useful tool to establish intra-luminal pathology like ulceration as a cause of retained endoscopic capsule.

Besides some cases of acute intestinal obstruction, there are only a few more complications reported in the literature due to a retained capsule. In fact, bowel perforation and capsule disintegration have already been reported, but only in case reports [54, 55].

#### **3.3 Treatment of bleeding lesions**

CD may be associated with mild gastrointestinal bleeding while major hemorrhage is a rare complication. In addition, a definitive bleeding site is not identified in most patients. In fact, hemorrhage is frequently attributed to diffuse areas of active inflammation [56]. The majority of bleeds originate from the ileum and colon and only a small number of episodes have been attributed to a jejunal or upper gastrointestinal source.

Initial management of major hemorrhage should always include primary resuscitation, as in any individual with a significant gastrointestinal bleed [57]. Once a patient is stabilized, diagnostic maneuvers are of primary importance. The site of bleeding can be identified by endoscopy, angiography or labeled red blood cell scans. However, clinicians should be aware that identifying a precise source of bleeding is difficult and salvage surgery may be necessary.

In the context of CD, urgent device-assisted enteroscopy for large-volume bleeding should be performed via the retrograde route, given the propensity of these conditions to involve the distal small bowel [52]. When it is identified, the source of bleeding is more commonly described as a deep ulcer eroding into a blood vessel and therapy may be attempted [56]. Endoscopy therapy includes thermocoagulation alone or a combination of epinephrine injection and bipolar coagulation [58]. Application of hemoclips may be compromised in the presence of inflamed and friable mucosa. On rare occasions, a large pseudopolyp in the ileum or colon has been identified as the source of bleeding; polypectomy should be performed in these cases. Although endoscopic therapy can stop acute bleeding, it does not promote mucosal healing and therefore cannot prevent rebleeding. In fact, the risk of rebleeding associated with endoscopic hemostasis is about 50% [56]. Thus, therapies that can induce and maintain mucosal healing are necessary to prevent rebleeding, such as anti-TNF agents.

Intraoperative enteroscopy may be the most reliable method to achieve a complete small bowel evaluation. It involves evaluation of the small bowel at laparotomy and may be performed orally, rectally or via an enterotomy. Upper endoscopes, colonoscopes, push enteroscopes and balloon-assisted scopes have all been used. Although it is highly invasive and associated with major complications, it may help in the identification of the bleeding source and in planning the optimal therapeutic intervention [59].

When CD is complicated by obscure bleeding, video capsule endoscopy and device-assisted endoscopy may identify and treat the bleeding source beyond the reach of standard endoscopes [1]. In fact, video capsule endoscopy has a fundamental role in diagnosing obscure gastrointestinal bleeding in patients with CD. It has been found to be superior to push enteroscopy and small bowel radiography. Video capsule endoscopy should be performed immediately after a negative upper and lower endoscopy as a screening method. The results of video capsule endoscopy should guide the use of device-assisted endoscopy, which aims at both the confirmation and treatment of the detected lesions.

## **3.4 Intralesional injection**

Although local injection of immunomodulatory drugs like corticosteroids and infliximab CD stricture may look like an attractive therapeutic strategy [60], the available evidence is inconsistent. Some studies have shown benefit of intralesional injection of triamcinolone [61] and infliximab [62] at the time of balloon dilatation of CD. On the other hand, East et al. compared local quadrantic injection of triamcinolone after endoscopic balloon dilatation of Crohn's ileocolonic anastomotic strictures vs. saline placebo and showed that a single treatment of intrastricture triamcinolone injection did not reduce the time to redilatation [63]. Moreover, there was a trend toward a worse outcome. Similarly, Atreja et al. reported that intralesional steroid or biologics injection did not decrease the need for re-intervention or surgery for either primary or anastomotic strictures [64]. Until now, there is no strong evidence supporting the injection of drugs at the site of strictures and larger series are needed to evaluate the real effectiveness of these techniques in the treatment of patients with obstructive strictures.

## **4. Postoperative recurrence**

In the natural history of CD, intestinal resection is unavoidable in a significant proportion of patients. The majority of individuals will develop disease recurrence at or above the anastomosis, which usually occurs within a few weeks to months after ileocolonic resection [65].

Diagnosis of postoperative recurrence is based on clinical symptoms, serum and fecal markers, radiological and endoscopic findings. Nevertheless, ileocolonoscopy remains the gold standard, by defining the presence and severity of morphological recurrence [41]. It is recommended within the first 6 to 12 months after surgery, when treatment decisions may be affected. In fact, endoscopic recurrence usually precedes clinical recurrence and severe endoscopic recurrence predicts a poor prognosis. Rutgeerts et al. developed an endoscopic scoring system to assess postoperative recurrence in patients having ileocolonic resection [66]. The patients were stratified into five groups according to the endoscopic severity (**Table 5**). An


**39**

*Endoscopy in Small Bowel Crohn's Disease DOI: http://dx.doi.org/10.5772/intechopen.95925*

disease are overcome with this score.

minimize the risk of retention.

**5. Small bowel malignancy**

endoscopic balloon dilatation [71].

**6. Conclusions**

endoscopic score of i0 or i1 correlated with a low risk of endoscopic progression and had clinical recurrence rates of less than 10% over 10 years. An endoscopic score of i2 or above suggests mucosal inflammation and should prompt considered treatment escalation [14]. However, it is important to note that the i2 category, including aphthous lesions in the terminal ileum as well as ileocolonic anastomosis lesions, had a heterogeneous recurrence risk. Therefore, a modified Rutgeerts' score has recently emerged in which i2 is subdivided into i2a for lesions confined to the ileocolonic anastomosis, including anastomotic stenosis, and i2b for more than 5 aphthous ulcers or larger lesions, with normal mucosa in between, in the neoterminal ileum, with or without anastomotic lesions [67]. With this modified score, stenosis and/or ulceration of the anastomosis, which might simply be related to ischemia or staples, do not define recurrent disease and have no prognostic or therapeutic implications [68]. Thus, possible confounding factors for recurrent

Video capsule endoscopy can also be used to assess postoperative recurrence of CD and should be considered if ileocolonoscopy is contraindicated or unsuccessful. Video capsule endoscopy may identify lesions in the small bowel that have not been detected by ileocolonoscopy after ileocolic resection. An important advantage of capsule endoscopy is the ability to detect proximal small bowel recurrence. However, patency capsule evaluation is recommended before capsule endoscopy to

Patients with CD are at an increased risk of developing malignancy, which is more frequent in the CD-affected colon. However, those with small bowel involvement may also develop cancer, which can be difficult to diagnose. In fact, compared with an age-matched population, patients with CD have an 18-fold increased incidence of small bowel malignancy and only a minority are detected at an early stage [69]. Adenocarcinoma is the most common form of all small bowel cancer. Prognosis of small bowel adenocarcinoma is poor and the mortality at 1 and 2 years

Early detection of small bowel carcinoma remains a problem. Radiological imaging and video capsule endoscopy could potentially detect malignancies at an early stage. However, differentiation between inflammatory stenosis and cancer is difficult. In these cases, device-assisted enteroscopy should be performed to direct visualization and tissue sampling. Furthermore, these procedures are not routinely used for screening asymptomatic individuals. Therefore, every patient who has a change of symptoms should perform further exams as this might be an indicator of malignancy [69]. Moreover, most of the small bowel carcinoma in CD is located in strictures, so the endoscopist should have a low threshold for taking biopsies before

Endoscopy has major implications for diagnosis, classification, therapeutic decision and prognosis of CD. Ileocolonoscopy with biopsy is the first-line exam for suspected CD. However, the small bowel is one of the most affected areas by inflammation, which may skip the terminal ileum and not be detected by ileoscopy. In fact, small intestine involvement is more difficult to assess by conventional endoscopy. In addition, radiological examinations, including both magnetic

ranges from 30–60% dependent on the stage of cancer [70].

**Table 5.**

*Rutgeerts´ score. Postoperative recurrence: Rutgeerts score = i2-i4.*

#### *Endoscopy in Small Bowel Crohn's Disease DOI: http://dx.doi.org/10.5772/intechopen.95925*

*Endoscopy in Small Bowel Diseases*

**3.4 Intralesional injection**

mation and treatment of the detected lesions.

ment of patients with obstructive strictures.

**Endoscopic description of findings**

confined to ileocolonic anastomosis i3 Diffuse aphthous ileitis with diffusely inflamed mucosa

*Rutgeerts´ score. Postoperative recurrence: Rutgeerts score = i2-i4.*

i4 Diffuse inflammation with large ulcers, nodules and/or narrowing

**4. Postoperative recurrence**

after ileocolonic resection [65].

has been found to be superior to push enteroscopy and small bowel radiography. Video capsule endoscopy should be performed immediately after a negative upper and lower endoscopy as a screening method. The results of video capsule endoscopy should guide the use of device-assisted endoscopy, which aims at both the confir-

Although local injection of immunomodulatory drugs like corticosteroids and infliximab CD stricture may look like an attractive therapeutic strategy [60], the available evidence is inconsistent. Some studies have shown benefit of intralesional injection of triamcinolone [61] and infliximab [62] at the time of balloon dilatation of CD. On the other hand, East et al. compared local quadrantic injection of triamcinolone after endoscopic balloon dilatation of Crohn's ileocolonic anastomotic strictures vs. saline placebo and showed that a single treatment of intrastricture triamcinolone injection did not reduce the time to redilatation [63]. Moreover, there was a trend toward a worse outcome. Similarly, Atreja et al. reported that intralesional steroid or biologics injection did not decrease the need for re-intervention or surgery for either primary or anastomotic strictures [64]. Until now, there is no strong evidence supporting the injection of drugs at the site of strictures and larger series are needed to evaluate the real effectiveness of these techniques in the treat-

In the natural history of CD, intestinal resection is unavoidable in a significant proportion of patients. The majority of individuals will develop disease recurrence at or above the anastomosis, which usually occurs within a few weeks to months

Diagnosis of postoperative recurrence is based on clinical symptoms, serum and fecal markers, radiological and endoscopic findings. Nevertheless, ileocolonoscopy remains the gold standard, by defining the presence and severity of morphological recurrence [41]. It is recommended within the first 6 to 12 months after surgery, when treatment decisions may be affected. In fact, endoscopic recurrence usually precedes clinical recurrence and severe endoscopic recurrence predicts a poor prognosis. Rutgeerts et al. developed an endoscopic scoring system to assess postoperative recurrence in patients having ileocolonic resection [66]. The patients were stratified into five groups according to the endoscopic severity (**Table 5**). An

i2 >5 aphthous ulcers with normal intervening mucosa, skip areas of larger lesions or lesions

**38**

**Table 5.**

**Rutgeerts´ score**

i0 No lesions

i1 ≤5 aphthous ulcers

endoscopic score of i0 or i1 correlated with a low risk of endoscopic progression and had clinical recurrence rates of less than 10% over 10 years. An endoscopic score of i2 or above suggests mucosal inflammation and should prompt considered treatment escalation [14]. However, it is important to note that the i2 category, including aphthous lesions in the terminal ileum as well as ileocolonic anastomosis lesions, had a heterogeneous recurrence risk. Therefore, a modified Rutgeerts' score has recently emerged in which i2 is subdivided into i2a for lesions confined to the ileocolonic anastomosis, including anastomotic stenosis, and i2b for more than 5 aphthous ulcers or larger lesions, with normal mucosa in between, in the neoterminal ileum, with or without anastomotic lesions [67]. With this modified score, stenosis and/or ulceration of the anastomosis, which might simply be related to ischemia or staples, do not define recurrent disease and have no prognostic or therapeutic implications [68]. Thus, possible confounding factors for recurrent disease are overcome with this score.

Video capsule endoscopy can also be used to assess postoperative recurrence of CD and should be considered if ileocolonoscopy is contraindicated or unsuccessful. Video capsule endoscopy may identify lesions in the small bowel that have not been detected by ileocolonoscopy after ileocolic resection. An important advantage of capsule endoscopy is the ability to detect proximal small bowel recurrence. However, patency capsule evaluation is recommended before capsule endoscopy to minimize the risk of retention.

## **5. Small bowel malignancy**

Patients with CD are at an increased risk of developing malignancy, which is more frequent in the CD-affected colon. However, those with small bowel involvement may also develop cancer, which can be difficult to diagnose. In fact, compared with an age-matched population, patients with CD have an 18-fold increased incidence of small bowel malignancy and only a minority are detected at an early stage [69]. Adenocarcinoma is the most common form of all small bowel cancer. Prognosis of small bowel adenocarcinoma is poor and the mortality at 1 and 2 years ranges from 30–60% dependent on the stage of cancer [70].

Early detection of small bowel carcinoma remains a problem. Radiological imaging and video capsule endoscopy could potentially detect malignancies at an early stage. However, differentiation between inflammatory stenosis and cancer is difficult. In these cases, device-assisted enteroscopy should be performed to direct visualization and tissue sampling. Furthermore, these procedures are not routinely used for screening asymptomatic individuals. Therefore, every patient who has a change of symptoms should perform further exams as this might be an indicator of malignancy [69]. Moreover, most of the small bowel carcinoma in CD is located in strictures, so the endoscopist should have a low threshold for taking biopsies before endoscopic balloon dilatation [71].

### **6. Conclusions**

Endoscopy has major implications for diagnosis, classification, therapeutic decision and prognosis of CD. Ileocolonoscopy with biopsy is the first-line exam for suspected CD. However, the small bowel is one of the most affected areas by inflammation, which may skip the terminal ileum and not be detected by ileoscopy. In fact, small intestine involvement is more difficult to assess by conventional endoscopy. In addition, radiological examinations, including both magnetic

#### *Endoscopy in Small Bowel Diseases*

resonance imaging and computed tomography, may not detect disease of the small bowel, especially in mild lesions.

Until a decade ago, mucosal visualization of the small intestine was limited to the reach of the push enteroscope. The advent of video capsule endoscopy and device-assisted endoscopy is revolutionizing small bowel CD diagnosis and treatment. In fact, these techniques allowed direct visualization of the entire small intestine, which would alter patient management, especially in those with inconclusive results from conventional studies. Device-assisted endoscopy has also the ability to obtain biopsies for histopathology and the potential for therapeutic intervention. Finally, video capsule endoscopy and device-assisted endoscopy play an important role in assessing response to therapy.
