Colonoscopy:
A colonoscopy is a diagnostic procedure performed to examine the rectum and the large intestine along its entire length. In most cases, the examination also includes the distal part of the small intestine. The procedure is usually conducted under deep sedation, and in children, it is often performed with certified anesthesia. During the procedure, a flexible tube is inserted by the physician through the anus, and at its tip, there is a tiny camera to inspect for inflammation and determine its location and severity. Patients suffering from colitis for ten years or more should undergo colonoscopy every 1-3 years to detect early changes associated with chronic inflammation if present. Three days before the procedure, patients are given specific instructions for dietary changes and may be prescribed different preparations for bowel cleansing.
Sigmoidoscopy:
Sigmoidoscopy is a similar procedure to colonoscopy but much shorter, as it examines only the rectum and the end of the large intestine, called the sigmoid colon. This shorter examination is sufficient in cases where a general assessment of disease severity is needed, such as to evaluate treatment or when atypical symptoms are present.
Gastroscopy:
Gastroscopy is a diagnostic procedure performed to examine the stomach, duodenum, and the first part of the small intestine (upper gastrointestinal tract). During the procedure, a flexible tube is passed through the mouth, and at its tip, there is a tiny camera to check for signs of inflammation in the upper digestive tract. This can be indicative of certain conditions, such as Crohn's disease, and helps in planning the appropriate treatment. In children, where the examination is performed under anesthesia, gastroscopy is a routine part of assessing inflammatory bowel disease. In adults, the procedure is usually performed when specific symptoms are present.
Abdominal X-ray:
Abdominal X-ray plays a secondary role in diagnosing inflammatory bowel diseases, though certain clues in the X-ray can point to this diagnosis. Regular abdominal X-rays are essential for evaluating acute conditions related to Crohn's disease, such as intestinal obstruction or perforation, and for diagnosing severe colitis complications like Toxic Megacolon.
Barium Swallow:
The barium swallow test is designed to demonstrate the small intestine, which is not adequately visualized during colonoscopy or gastroscopy. Before the test, the patient drinks a contrast material, and for about two to three hours, radiologists monitor its progression through the small intestine. The test can reveal inflammation of the small intestine, indicative of Crohn's disease, and help locate and characterize the disease (such as intestinal strictures or fistulas resulting from Crohn's disease). This information is crucial for diagnosis, treatment planning, and determining the future risk of inflammation. However, the disadvantage of the test is its use of radiation, and its accuracy depends on the skill of the practitioner. Additionally, it does not visualize the large intestine as well as colonoscopy and gastroscopy.
Computed Tomography Enterography (CTE):
CTE is a diagnostic test capable of producing a high-quality three-dimensional image of the body's organs using X-ray technology. The technology has significantly improved in recent years, and now the resolution is so good that, with proper use of contrast materials, it can demonstrate the large intestine better than a barium swallow. CTE provides an excellent view of all abdominal organs, not just the intestine, and can diagnose other pathologies such as fistulas, abscesses, or free fluid. The main drawback of the test is the radiation associated with it, although modern CT devices have reduced the radiation exposure significantly.
Magnetic Resonance Enterography (MRE):
MRE is a specialized MRI test capable of providing a highly detailed and non-radiation image of the intestine. It offers a significant advantage over older imaging techniques by not using radiation. However, MRE is relatively challenging to perform and may not be suitable for very young children in most centers. One additional benefit is that recent research has shown that MRE can provide data on disease activity without the need for endoscopy. Since there isn't always a direct correlation between clinical disease activity and the severity of inflammation in Crohn's disease, MRE provides a non-invasive way to assess the degree of inflammation in the small intestine. Consequently, a thorough and efficient follow-up of inflammatory bowel disease, especially Crohn's disease, may include a combination of different tests, such as colonoscopy, MRE, and ultrasound (as explained later).
Capsule endoscopy
This examination allows visualization of the small intestine, which is not easily accessible using traditional gastroscopy or colonoscopy in most cases. Patients aged ten and above swallow a capsule that transmits three images per second to an external device that collects this data while the capsule moves through the intestine. In younger children who cannot swallow the capsule, it can be placed in the small intestine via gastroscopy. After the examination, the images can be viewed as a video on the computer, allowing the identification of suspected areas of inflammation or ulcers, characteristic of Crohn's disease. Capsule endoscopy is more accurate than MRE (Magnetic Resonance Enterography) in detecting subtle findings based on the intestinal surface and in visualizing the upper and middle parts of the small intestine. Moreover, the non-invasive visualization of the entire small bowel allows for an accurate diagnosis of pathologies in the duodenum.
However, compared to MRE, capsule endoscopy has some limitations: it cannot see beyond the inner lining of the intestine, requires bowel preparation (the specific protocols vary between centers), involves swallowing a large capsule, and carries a risk of capsule retention in areas with strictures caused by chronic inflammation. To reduce this risk, a dissolvable capsule can be ingested before the examination to ensure successful passage through the entire intestine or monitored through abdominal X-rays.
Capsule endoscopy is essential in cases where colonoscopy and gastroscopy yielded normal results, but there is still suspicion of Crohn's disease. While active Crohn's disease in the middle part of the small intestine is uncommon, capsule endoscopy has become more frequently used for diagnosis due to its efficiency.
Ultrasound
Ultrasound technology has continuously improved, enhancing resolution and performance. Skillful hands can use ultrasound to demonstrate the thickness of the bowel wall (a suspicious finding for inflammation in the small intestine), the presence of abdominal abscesses, free abdominal fluid, and other rare complications. Ultrasound is excellent for a non-specific survey when suspicion arises and is also used for monitoring known cases of Crohn's disease and occasionally for ulcerative colitis. The procedure is straightforward, inexpensive, and radiation-free. Recently, we have begun to utilize ultrasound at the bedside to monitor Crohn's disease during regular visits, enabling better treatment decisions. We expect the use of bedside ultrasound to become more prominent and a key tool in the assessment and treatment of Crohn's disease, and to a lesser extent, ulcerative colitis. The drawback is its slightly lower accuracy compared to other imaging modalities discussed earlier, and it depends on the skill of the examiner. Recently, more advanced methods have been developed for utilizing ultrasound in inflammatory bowel diseases, such as drinking or injecting contrast agents.
Additional tests
Other tests, such as using radiolabeled white blood cells localized in areas of inflammation, exist worldwide but are not routinely used in Israel. These tests provide additional information compared to the aforementioned examinations but are only occasionally required.