Unveiling the superior diagnostic efficacy of double-balloon endoscopy compared to small intestine dual-energy CT enterography in small bowel Crohn's disease.

Background: Dual-energy computed tomography enterography (DECTE) has significantly improved gastrointestinal imaging quality. Double-balloon endoscopy (DBE) has enabled comprehensive visualization of the small intestinal mucosa. This study aimed to assess the diagnostic efficacy of small-intestine DECTE and DBE for small bowel Crohn's disease (CD).

Methods: This retrospective study was conducted between 1 July 2016 and 1 November 2023 at the First Affiliated Hospital of Soochow University. The study included 72 CD patients who underwent both DECTE and DBE, with 4 patients repeating both procedures within 3 months.

Results: The diagnostic rate of small bowel CD using DBE was 80.3%, which was higher than that using DECTE (65.8%, P = 0.044). The combined small bowel CD diagnostic rate was 89.5%, which was higher than that of DECTE alone (P < 0.001). The detection rate of stenosis using DBE was 46.1%, which was higher than that using DECTE (13.2%; P < 0.001). The combined detection rate of stenosis was 52.6%, which was higher than that of DECTE alone (P < 0.001). For ulcers, DBE had a higher detection rate (73.7%) than DECTE (7.9%; P < 0.001). The combined ulcer detection rate was 76.3%, which was higher than that of DECTE alone (P < 0.001). The detection rate of long ulcers (≥ 2 cm) and non-ileocecal ulcers by DBE were both 17.9%. For patients with abdominal pain, DBE had a diagnostic rate of 79.4%, higher than 63.5% of DECTE (χ2 = 3.889, P = 0.049). The combined diagnostic rate was 87.3%, which was higher than that of DECTE alone (χ2 = 9.626, P = 0.002). For patients with diarrhoea, the DBE's diagnostic rates were 86.8% and 68.4% for DECTE (P = 0.097). The combined diagnostic rate was 94.7%, higher than DECTE alone (χ2 = 7.092, P = 0.008). For patients with other symptoms, such as abdominal distension or vomiting, the DBE diagnostic rate was 79.4% compared with 61.8% for DECTE (P = 0.183). The combined diagnostic rate was higher than DECTE alone (χ2 = 6.620, P = 0.010). Furthermore, notable differences in C-reactive protein, erythrocyte sedimentation rate, faecal calprotectin, haemoglobin, platelet count, albumin, haematocrit, Crohn's Disease Activity Index scores, and Simple Endoscopic Score for Crohn's Disease scores were observed between ulcer-positive and ulcer-negative patients detected by DBE (P < 0.05), whereas DECTE did not show significant differences (P > 0.05).

Conclusions: DBE or the combined use of DECTE and DBE provides superior diagnostic performance for small bowel CD, particularly in detecting stenosis and ulcers, compared with DECTE alone. DBE can be used to identify long ulcers and non-ileocecal ulcers. Moreover, DBE helps diagnose small bowel CD across different clinical manifestations and assess disease activity in various inflammatory states.