Increased Intestinal Permeability in Relatives of Patients With Crohn’s Disease Is Not Associated With Small Bowel Ulcerations

Accepted Manuscript Increased intestinal permeability in relatives of patients with Crohn’s Disease is not associated with small bowel ulcerations Christopher W. Teshima, Karen J. Goodman, Mohamed El-Kalla, Samina Turk, Wael El-Matary, Rosica Valcheva, Ronda Danchak, Marilyn Gordon, Peter Ho, Amanda Mullins, Daniel Wong, Dina Kao, Jonathan Meddings, Hien Huynh, Levinus A. Dieleman

PII: DOI: Reference:

S1542-3565(17)30259-8 10.1016/j.cgh.2017.02.028 YJCGH 55130

To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 18 February 2017 Please cite this article as: Teshima CW, Goodman KJ, El-Kalla M, Turk S, El-Matary W, Valcheva R, Danchak R, Gordon M, Ho P, Mullins A, Wong D, Kao D, Meddings J, Huynh H, Dieleman LA, Increased intestinal permeability in relatives of patients with Crohn’s Disease is not associated with small bowel ulcerations, Clinical Gastroenterology and Hepatology (2017), doi: 10.1016/j.cgh.2017.02.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Increased intestinal permeability in relatives of patients with Crohn’s Disease is not associated with small bowel ulcerations

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Christopher W. Teshima,1,2 Karen J. Goodman,1 Mohamed El-Kalla,1 Samina Turk,1 Wael El-Matary,3 Rosica Valcheva,1 Ronda Danchak,4 Marilyn Gordon,4 Peter Ho,1 Amanda Mullins,4 Daniel Wong,1 Dina Kao,1 Jonathan Meddings,5 Hien Huynh,4

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Levinus A. Dieleman1

Division of Gastroenterology and CEGIIR, University of Alberta, Edmonton, Alberta,

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Canada.

Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada

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Section of Pediatric Gastroenterology, University of Manitoba, Winnipeg, Canada

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Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.

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Department of Medicine, University of Calgary, Calgary, Alberta, Canada.

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Short title: Intestinal permeability in CD relatives

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Grant support: Broad Medical Research Program (grant IBD-0243-2) Dr. Teshima was supported by a Canadian Institutes of Health Research (CIHR) /

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Canadian Association of Gastroenterology (CAG) Research Fellowship Award (sponsored by Ferring Canada).

Disclosures: All authors have no potential financial disclosures.

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Corresponding author: Levinus A. Dieleman, MD PhD, Professor of Medicine

2-24 Zeidler Ledcor Centre, 130 University Campus Edmonton, AB, T6G 2X8 Canada Tel: 1-780-492-8691 Fax: 1-780-492-8121

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Email: [email protected]

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Dept. of Medicine, Division of Gastroenterology

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Abbreviations: Crohn’s Disease

CI

Confidence interval

FC

Fecal calprotectin

IBD

Inflammatory bowel disease

L:M

Lactose:mannitol ratio

NSAID

Non-steroidal anti-inflammatory drug

OR

Odds ratio

VCE

Video capsule endoscopy

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CD

Writing assistance: none

Author contributions: •

Study concept and design: L. Dieleman, J. Meddings, C. Teshima

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Funding/grant acquisition: L. Dieleman, J. Meddings, C. Teshima

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Data collection and conduct of study: R. Danchak, M. Gordon, M. El-Kalla, W. El-Matary, P. Ho, A. Mullins, R. Valcheva, C. Teshima, S. Turk, D. Wong, D. Kao Analysis and interpretation of data: L. Dieleman, M. El-Kalla, W. El- Matary, K. Goodman, H. Huynh, J. Meddings, C. Teshima

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•

Statistical analysis: K. Goodman, C. Teshima

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Drafting of the manuscript: C. Teshima

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Critical revision of the manuscript: L. Dieleman, W. El -Matary, K Goodman, H.

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Huynh, J. Meddings, C. Teshima

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Administrative, technical and material support: R. Danchak, M. Gordon, M. ElKalla, P. Ho, A. Mullins, R. Valcheva, S. Turk, D. Wong Study supervision: L. Dieleman

Word Count:

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Manuscript (including references) – 3725

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abstract (includes keywords) - 314

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ABSTRACT Background & Aims: Many first-degree relatives of patients with Crohn’s disease (CD) have increased intestinal permeability. Video capsule endoscopy (VCE) is the most

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sensitive imaging test to identify small bowel mucosal lesions that indicate subclinical

CD. We aimed to estimate the association of increased intestinal permeability with small

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bowel ulcerations detectable by VCE in healthy first-degree relatives of patients with CD.

Methods: We conducted a cross-sectional study of 223 healthy, asymptomatic first-

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degree relatives of patients with CD (parents, siblings, and children; 9–45 years old) enrolled at the University of Alberta between 2009 and 2012. Patients were given the lactulose and mannitol test to measure small bowel permeability; we used highperformance liquid chromatography to measure concentrations of lactulose and mannitol

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in urine samples (increased permeability defined as a ratio of lactulose:mannitol 0.025 or greater). Patients with increased permeability (n=39) and randomly selected subjects with normal permeability (n=59) were then examined by VCE for signs of small bowel

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inflammation and subclinical CD. The prevalence of small bowel lesions was compared between groups. We performed logistic regression analyses to estimate odds ratios for the

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association of small bowel ulcerations with intestinal permeability.

Results: Among 223 first-degree relatives of patients with CD, 30% were found to have increased intestinal permeability; VCE examination found 24% of subjects to have 3 or more small bowel ulcers. Three or more small bowel ulcers were detected in 28% of patients with increased intestinal permeability and 20% of patients with normal intestinal

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permeability (P=.37). The adjusted odds ratio for the association 3 or more small bowel ulcers with increased intestinal permeability was 1.5 (95% CI, 0.6–3.8) (P=.46).

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Conclusion: Thirty percent of healthy, asymptomatic first-degree relatives of patients

with CD have increased intestinal permeability. However, a strong association of small

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bowel ulceration seen on VCE with increased intestinal permeability was not observed.

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KEY WORDS: family member, inflammatory bowel disease, pathogenesis, risk factor

INTRODUCTION

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Despite significant progress in the understanding of Crohn’s disease (CD) pathogenesis, its underlying etiology remains obscure. Children and siblings of patients with CD have increased risks of CD compared to the general population.1,2 Increased small bowel

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permeability, observed in many patients with CD, has also been detected in up to 20% of asymptomatic first-degree relatives.3 Increased risk of both permeability defects and CD has been linked to genetic loci shared by patients and first-degree relatives,4,5 suggesting

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a genetic link between susceptibility to CD and abnormal intestinal permeability. These observations led to the hypothesis that impaired small intestinal barrier function plays a

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role in the pathogenesis of CD.3 However, the significance of abnormal intestinal permeability in first-degree relatives of patients with CD remains unknown. In particular, it is unclear whether healthy first-degree relatives with abnormal intestinal permeability have asymptomatic CD or whether they have abnormal intestinal permeability without

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macroscopic mucosal inflammation. The aim of this study was to use video capsule endoscopy (VCE) to investigate whether the increased occurrence of abnormal intestinal permeability in first-degree relatives is a manifestation of subclinical CD. VCE is the

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value of 96%.8

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most sensitive test for the detection of small bowel CD,6,7 with a negative predictive

METHODS

Study design and population We conducted a cross-sectional study to estimate the prevalence of abnormal intestinal permeability among first-degree relatives of patients with CD, followed by a case-control study with cases and controls selected from the cross-sectional study population, which

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comprised first-degree relatives (parents, siblings, children) of patients with CD attending our clinics. We used a standardized questionnaire (see Supplemental materials) to screen first-degree relatives for eligibility based on inclusion and exclusion criteria. Eligible

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subjects provided written, informed consent. For subjects under 18 years of age, we

obtained written assent from the child and parental consent. The study was approved by the Health Research Ethics Board of the University of Alberta (approved April 25, 2009).

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All authors had access to the study data and approved the final manuscript.

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Cross-sectional Study Inclusion and Exclusion Criteria

Included subjects were: first-degree relatives of a patient with CD; between the ages of 9 and 45; free of symptoms suggestive of inflammatory bowel disease (IBD); and able to provide written, informed consent in English. We excluded individuals with symptoms

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suggestive of IBD or conditions that can affect intestinal permeability (celiac disease, diabetes, and pregnancy).9 We also excluded individuals taking medications that could potentially treat CD or non-steroidal anti-inflammatory drugs (NSAIDs) that can affect

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intestinal permeability and cause small bowel ulcers10 (see Supplemental materials). Celiac disease (which can cause abnormal intestinal permeability and VCE

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abnormalities11) was excluded using serum anti-transglutaminase IgA and total IgA.

Intestinal permeability

We performed permeability testing using the lactulose/mannitol test, a validated standard for the measurement of intestinal permeability, described elsewhere.12 The test involves swallowing a sugar-drink containing 100 g sucrose, 5 g lactulose and 2 g mannitol in 450

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mL water followed by an overnight urine collection. For children weighing less than 46 kg, we used a modified weight-based regimen previously described.13 We used highperformance liquid chromatography to measure the concentrations of lactulose and

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mannitol in urine samples. The ratio of the fractional urinary excretion of lactulose to that of mannitol (L:M ratio) represents the permeability of the small bowel modified by its

Video capsule endoscopy

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and abnormal intestinal permeability as a L:M ≥ 0.025.

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surface area. We defined normal small bowel intestinal permeability as a L:M < 0.025

VCE was offered to all cases with abnormal intestinal permeability and a random sample of subjects with normal intestinal permeability was selected as controls, aiming for a case-control ratio of 2:1. All subjects in the case-control study underwent VCE within 1

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month of their permeability tests. We used the Olympus EndoCapsuleTM system (Olympus, Center Valley, Pennsylvania) to perform VCE.

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Detection of Subclinical CD

Two physicians (CT, WEM) experienced in VCE and blinded to the intestinal

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permeability status of the subjects reviewed the VCE videos independently. We defined an abnormal VCE consistent with subclinical CD as the presence of 3 or more small intestinal ulcers since this was the most widely accepted case definition for the diagnosis of CD by VCE during study design.14 The images were also assessed for villous edema and luminal stenosis, which together with ulcers comprise the 3 variables that constitute the ‘Capsule endoscopy scoring index for small bowel mucosal inflammatory change’

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(“Lewis score”). 15 This index generates a numerical score based on the number of lesions together with their extent and location that stratifies a VCE into three categories: normal (score < 135), mild inflammation (score 135 – 790), or moderate-to-severe

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inflammation (score ≥ 790). The final number of small bowel ulcers and “Lewis score” for each subject was determined by taking the mean number of ulcers and the mean

Lewis score from the two VCE readers. Any subject with an abnormal VCE suspicious

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for CD was subsequently offered colonoscopy, gastroscopy and CT enterography as part

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of standard clinical care.

Fecal calprotectin

We asked subjects who underwent VCE to provide a one-time stool sample for measurement of fecal calprotectin (FC) levels, a marker that correlates with intestinal

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inflammatory activity in CD.16 FC levels were determined using the Bühlmann Calprotectin ELISA test kit (ALPCO Diagnostics, Salem, NH). We classified FC values

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below 50 µg/g as normal.

Statistical analysis

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Analytic goals of this study included estimating the prevalence of abnormally increased small bowel permeability in healthy, asymptomatic first-degree relatives within categories of selected variables, and estimating the association of subclinical CD with the odds of abnormal intestinal permeability. We defined subclinical CD in 2 ways: primarily, based on the number of ulcers detected on VCE, and secondarily based on the ‘Lewis score’. We dichotomized small bowel ulceration as normal (≤ 2 ulcers) or

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abnormal (≥ 3 ulcers) and the ‘Lewis score’ as normal and abnormal (Lewis score > 135). We also estimated associations of FC levels with both intestinal permeability and small

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bowel ulceration.

We used logistic regression to estimate odds ratios (OR) for the association of small

bowel ulceration status and the ‘Lewis score’ with intestinal permeability, adjusting for

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age and sex. We also estimated associations for FC levels. We present 95% confidence

intervals (CI) for the OR as a measure of statistical precision reflecting the range of OR

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values compatible with the data (the narrower the interval, the more precise the estimate). We used the statistical software Stata 10.1 (Stata Corp, College Station, TX) to perform the analyses.

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A calculation was performed during the study design to determine the sample size necessary to achieve adequate statistical precision. Given reports in the literature10,17 that 5% of healthy individuals not exposed to NSAIDs have small bowel ulcerations seen on

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VCE, we assumed that 5% of first-degree relatives with normal intestinal permeability would have ≥ 3 small bowel ulcers. We assumed that if abnormal intestinal permeability

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was determined mainly by small bowel ulceration, then most subjects with abnormal intestinal permeability would have abnormal small bowel ulceration on VCE. Therefore, we postulated that a conservative estimate for a clinically relevant difference was for at least one-third of first-degree relatives with abnormal permeability to have ≥ 3 ulcers on VCE. Recognizing that we could expect 15 – 20% of first-degree relatives to have increased intestinal permeabiliy,3 we anticipated having more subjects with normal

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intestinal permeability than with abnormal intestinal permeability to consent for VCE. Therefore, the sample size calculation for the case-control study was based on an expected ratio of 2 subjects with normal permeability for every 1 subject with abnormal

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permeability undergoing VCE. Using these assumptions with a two-sided alpha level of 0.05 and power of 80%, we estimated that at least 52 subjects with normal intestinal permeability and 26 subjects with abnormal intestinal permeability were needed to

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undergo VCE for the case-control study. Assuming that 15% of first-degree relatives would have abnormal intestinal permeability, 173 subjects were required to undergo

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permeability testing for the cross-sectional study in order to generate sufficient subjects for the case-control study. After allowing for a 10% dropout rate, we estimated a sample size target of 200 first-degree relatives.

Study Enrollment

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RESULTS

Between April 2009 and December 2012, we approached 930 probands with CD, of

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which 346 (37%) agreed to allow study staff to contact their first-degree relatives. This led to the recruitment of 309 first-degree relatives meeting the inclusion and exclusion

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criteria, of which 227 (74%) underwent intestinal permeability testing. Four subjects were subsequently excluded due to positive anti-TTG serology suggestive of Celiac disease. The final study population consisted of 223 subjects; 64% female; mean age 24.9 years (range 9-45).

Intestinal Permeability

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One hundred fifty-seven (70%) subjects had normal intestinal permeability measurements, whereas 66 (30%) had abnormally increased permeability. The distribution of intestinal permeability status by sex, age and FC levels is shown in Table

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1. The prevalence of abnormal intestinal permeability was nearly identical in men and

women, whereas increased intestinal permeability was highest in younger age groups and appeared to decline with increasing age. In contrast, the prevalence of abnormal intestinal

Overall VCE findings

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Video Capsule Endoscopy

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permeability was similar in subjects with normal and with abnormal FC levels.

One hundred four study subjects agreed to VCE. Two subjects could not swallow the capsule and were excluded from the analysis. Four subjects had incomplete examinations:

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one capsule did not leave the stomach (suspected gastroparesis) and three capsules did not reach the cecum during the recording life of the battery. Thus, the complete small bowel VCE examination rate was 96%. There were no cases of capsule retention or any

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other complications. Overall, 23 (24%) subjects had 3 or more small bowel ulcers and were considered to have an abnormal VCE, with 18 (18%) graded as having mild to

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moderate inflammation and 4 (4%) graded as having severe inflammation, according to the Lewis classification. Thus, nearly one in four healthy, asymptomatic first-degree relatives had ulcerative changes of the small bowel suggestive of CD by existing VCE criteria. There was 86% agreement between the blinded VCE readers, generating a kappa score of 0.56, which is an acceptable level for a diagnostic test.

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VCE findings by intestinal permeability status The prevalence of abnormal small bowel ulceration was higher among subjects with abnormal intestinal permeability than with normal intestinal permeability (28% vs. 20%

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respectively, p=0.37) (Table 2). This difference was much smaller than hypothesized

when the study was designed, and therefore, estimated imprecisely. A somewhat larger difference was observed when comparing the prevalence of an abnormal Lewis

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classification between abnormal and normal intestinal permeability subgroups (31% vs. 17%, p=0.11) but once again, this was without statistical precision. Meanwhile, the mean

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number of ulcers appeared the same in abnormal and normal intestinal permeability groups (2.3 vs. 2.3; p=0.96). Overall, while there was an increased prevalence of abnormal intestinal permeability in the presence of abnormal small bowel ulceration, there was no evidence of a strong association linking the two variables, but a weaker

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association could not be excluded due to the imprecision of our estimates.

Fecal calprotectin measurements in VCE cohort

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FC measurements were performed in 81 of 98 subjects who completed VCE. Subjects with ≥ 3 small bowel ulcers on VCE had higher mean FC levels (156.6 vs. 73.1 ug/g;

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p=0.02) and contained a greater proportion with abnormal FC levels (71% vs. 33%; p<0.01) compared to the group with ≤ 2 small bowel ulcers on VCE.

Logistic regression

Logistic regression was performed to estimate unadjusted and adjusted odds ratios for the association of small bowel ulceration, age and sex with abnormal intestinal permeability

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(see Table 3). The analysis suggested the absence of a strong association between small bowel ulcers and intestinal permeability. Age remained a significant predictor of abnormal permeability after controlling for the other variables in the multivariable

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analysis, with the odds of increased intestinal permeability decreasing with each

increasing year of age (OR 0.95, 95% CI 0.91, 0.99; p=0.02). A separate analysis was

performed for FC, where there was evidence of an association of abnormal FC with small

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bowel ulcers (OR 4.9, 95% CI 1.5, 15.8), but less so with abnormal intestinal

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permeability (OR 1.5, 95% CI 0.6, 3.6), for which the comparison was underpowered.

DISCUSSION

Abnormal intestinal permeability is a consistent finding in most patients with CD as well as a substantial subset of their healthy, asymptomatic first-degree relatives,3 individuals

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who have the greatest risk of developing CD.2 This has raised suspicions that abnormal permeability may be involved in CD pathogenesis. Many theories have been proposed linking intestinal permeability to tight junction or other subcellular changes that may play

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a role in CD pathogenesis. However, an alternative theory postulates that abnormal intestinal permeability is due to subclinical CD. In this novel study, we sought to

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determine whether asymptomatic first-degree relatives with abnormal intestinal permeability have mucosal ulcerations suggestive of subclinical CD.

Our study reproduced previously reported findings showing that nearly 30% of firstdegree relatives had abnormally increased intestinal permeability.3 In addition, we observed that these permeability changes are most common in younger age groups and

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decrease with advancing age, a finding in agreement with the peak incidence of CD in young adults. Furthermore, by comparing the prevalence of abnormal intestinal permeability in first-degree relatives with and without abnormal small bowel ulceration,

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we observed the absence of a strong association between small bowel ulceration and intestinal permeability.

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It must be noted that our study was underpowered to detect a weak-moderate association, since the sample size calculation was based on the assumption that abnormal small bowel

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ulceration would only be present in 5% of FDR with normal permeability but was instead found in a surprisingly high 20%, whereas our assumption that one-third of first-degree relatives with abnormal permeability would have abnormal small bowel ulceration, being slightly higher than the observed prevalence of 28%. Thus, we had an insufficient sample

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size to estimate an odds ratio with a narrow CI corresponding to a modest association between small bowel ulceration and abnormal intestinal permeability. Nevertheless, by presenting evidence against a strong association between small bowel ulceration and

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abnormal intestinal permeability, this study does not support the hypothesis that small bowel ulcers are among the main causes of abnormal intestinal permeability in first-

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degree relatives.

A striking finding from this study is the high prevalence of small bowel ulcers seen on VCE amongst healthy, asymptomatic first-degree relatives with no history of regular NSAID use or recent NSAID exposure. Nearly one-in-four first-degree relatives had small bowel ulcers sufficient by some criteria to be considered diagnostic for small bowel

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CD,14 much higher than the reported incidence of 5% in non-NSAID controls.10 Longterm follow-up of these subjects would assess its clinical significance. If many of these first-degree relatives subsequently develop CD, then the ulcers seen on VCE may indeed

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represent early, subclinical disease. In contrast, if these subjects continue to be

asymptomatic and do not progress to CD, then it is unlikely that the ulcers observed in

this study are clinically relevant. If the latter holds true, it would call into question some

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of the existing criteria used for the VCE diagnosis of CD, confirming the need to use

alternative scoring systems such as the Lewis score or the Capsule Endoscopy Crohn’s

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Disease Activity Index to improve the specificity of VCE findings for CD.18,19

A major limitation of this important study was the lack of statistical power from insufficient sample size to detect modest differences in intestinal permeability between

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subjects with normal and abnormal small bowel ulceration. An ideal study design would have had all subjects undergo both permeability testing and VCE, but this was not feasible due to the costs of VCE. Furthermore, it was very challenging to recruit

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asymptomatic FDR, many of whom were children, to take part in this study that involved urine, blood and stool testing, and then a VCE procedure requiring fasting and purgative

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bowel prep. It was a considerable undertaking to recruit as many subjects as we did, and a similar study will likely not be repeated.

Another potential limitation is that our protocol did not restrict recruitment of multiple first-degree relatives from the same patient with CD, subjects who cannot be assumed to be independent because of shared genetic and environmental factors. However, fewer

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than 10 patients contributed more than one first-degree relative, with the proportion of related subjects being less than 10% of the study population. We accepted more than one first-degree relative from the same family due to the challenge of recruiting healthy

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volunteers: we approached nearly 1000 patients to enroll 227 subjects who underwent permeability testing.

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Finally, it would have been preferable to have all VCE subjects also undergo

ileocolonoscopy with mucosal biopsies from the terminal ileum and possibly even

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confocal endomicroscopy, which would have enabled us to identify inflammatory changes at the cellular and subcellular levels, but this was not feasible with asymptomatic volunteer subjects. Although subjects with small bowel ulcers on VCE were offered further work-up, given that they were asymptomatic all but one declined. This subject

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initially had a normal colonoscopy and MR enterography; however a few years later she developed symptoms and repeat investigations led to the eventual diagnosis of CD. Importantly, all first-degree relatives who participated in this study have been enrolled in

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an ongoing longitudinal follow-up study to assess for the subsequent development of CD. This long-term follow-up will provide insight as to whether abnormal intestinal

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permeability or the presence of small bowel ulcerations predicts future CD risk.

In summary, this landmark study showed that a substantial proportion of healthy, asymptomatic first-degree relatives of patients with CD have abnormally increased intestinal permeability, but did not observe a strong association with abnormal permeability and small bowel ulceration or other inflammatory changes seen on VCE.

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While the prevalence of abnormal small bowel ulcerations in this asymptomatic group of first-degree relatives was surprisingly high, its prognostic value for the development of

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CD will only be determined after long-term follow-up of this valuable cohort.

Table 1. Prevalence of Abnormal Intestinal Permeability by Study Variables Category Abnormal permeability Total

Cases

n

n

Prevalence %

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95% CI (%)

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223

66

30

24 - 36

Male

80

24

30

20 - 41

Female

143

42

29

22 - 38

10-19

90

34

38

20-29

63

16

25

30-39

38

10

≥ 40

32

6

Total

Abnormal

35

19

7 - 36

18

36

23 - 51

16

46

29 - 63

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50

15 - 38 13 - 43

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calprotectin

28 - 49

26

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Fecal

Normal

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Age group

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Sex

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Table 2. Distribution of ulceration and Lewis score by intestinal permeability status

Cases

Controls

(Abnormal)

(Normal)

Proportion of 39 cases

Proportion of 59 controls

n

Normal (0 – 2 ulcers)

28

72

Abnormal (≥ 3 ulcers)

11

28

Normal

27

69

Abnormal

12

95% CI (%)

47

80

67 – 89

15 – 45

12

20

11 – 33

52 – 83

49

83

71 – 92

10

17

8 - 29

17 – 48

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31

%

55 – 85

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Lewis classification

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Ulcer category

95% CI (%)

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n %

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Intestinal Permeability Status

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Table 3. Estimated odds ratios for the effect of small bowel ulceration on the

Unadjusted

OR

Adjusted

95% CI (p-value)

OR

95% CI (p-value)

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Variable

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prevalence odds of abnormal intestinal permeability

1.0

≥3

1.5

0.60, 4.0 (0.37)

1.5

0.55, 3.8 (0.46)

(per year increase)

0.95

0.91, 0.99 (0.02)

0.95

0.91, 0.99 (0.03)

Sex

Age

Female

1.0

0.94

0.41, 2.2 (0.89)

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Male

1.0

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0-2

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Small bowel ulcers

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1.0 0.84

0.35, 2.0 (0.69)

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Graham DY, Opekun AR, Willingham FF, et al. Visible small-intestinal mucosal injury in chronic NSAID users. Clin Gastroenterol Hepatol 2005;3:55–59.

18.

Niv Y, Ilani S, Levi Z, et al. Validation of the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score): a multicenter prospective study. Endoscopy 2012;44:21–26.

19.

Cotter J, Dias de Castro F, Magalhães J, et al. Validation of the Lewis score for the evaluation of small-bowel Crohn’s disease activity. Endoscopy 2015;47:330–335.

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CAPSULE ENDOSCOPY FOR THE ASSESSMENT OF ABNORMAL INTESTINAL PERMEABILITY IN CROHN’S DISEASE RELATIVES

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2. SUBJECT SCREENING AND DEMOGRAPHICS QUESTIONNAIRE

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STUDY SUBJECT ID: BR- └─┴─┴─┴─┘└─┴─┘ ENROLLMENT DATE:

└─┴─┴─┴─┘ YEAR

FOLLLOW-UP DATE:

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└─┴─┘ MONTH

Barcode

Urine

Stick code here

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Sample Type

Stick code here

Blood

Stick code here

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Stool

SUBJECT SCREENING & DEMOGRAPHICS

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MONTH

└─┴─┴─┴─┘ YEAR

└─┴─┘

└─┴─┘ DAY

└─┴─┘ DAY

Page 1 of 7

ACCEPTED MANUSCRIPT SUBJECT SCREENING AND REGISTRATION QUESTIONNAIRE

Capsule endoscopy for the assessment of abnormal intestinal permeability in Crohn’s disease relatives

Subject ID: BR- └─┴─┴─┴─┘ └─┴─┘ Date (today)

_____/____/____ Year/ Month/ Day

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Instructions to Research Coordinator

Consent signed : Signed by _____________ Subject Mother Father Guardian Yes

No

Not Applicable

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Assent Signed:

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Checklist:

This questionnaire is to be completed by Research Staff.

These questions are designed to provide the research team with the necessary details for subject enrolment in to this study. The questions will confirm eligibility.

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It is imperative that the subject be declared 'disease free' to be eligible for this study.

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Thank you.

SUBJECT SCREENING & DEMOGRAPHICS

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ACCEPTED MANUSCRIPT SUBJECT SCREENING AND REGISTRATION QUESTIONNAIRE

Capsule endoscopy for the assessment of abnormal intestinal permeability in Crohn’s disease relatives

Subject ID: BR- └─┴─┴─┴─┘ └─┴─┘ Date (today)

_____/____/____

Part 1- Subject Registration Information

______________________________________________ ______________________________________________ ______________________________________________

Sex:

Male

Enrollment Date:

Relation to Proband:

____/____/____

Age (must be age 10-

YEAR / MONTH/ DAY

45):

____/____/____ YEAR /MONTH/DAY

Contact Information:

Contact phone number(s)

Brother Mother Child

Sister Father

______________

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Date of Birth:

Female

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Last Name: First Name: Middle Name:

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Year/ Month/ Day

(____) _____ - ________ area code

(____) _____ - ________ area code

(____) _____ - ________

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Other phone number(s)

area code

(____) _____ - ________ area code

Mailing Address

___-______________________________ unit #

house #

Street Name

__________________________________

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City/Town

Father: _____________________

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For MinorsParent’s Name(s)

Caregiver Information: Family Physician/Pediatrician:

GI Specialist Treating Proband:

Prov.

Postal Code

Mother: _____________________

Guardian: _____________________

Name: _____________________

Office Telephone:

Name: _____________________

Office Telephone:

(____) _____ - ________ area code

(____) _____ - ________ area code

This personal information will be kept in a secure database form main database and will only be accessible for the regional coordinator and calling center for re-contact. This information will not be available to the individuals involved in data analysis. SUBJECT SCREENING & DEMOGRAPHICS

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ACCEPTED MANUSCRIPT SUBJECT SCREENING AND REGISTRATION QUESTIONNAIRE

Capsule endoscopy for the assessment of abnormal intestinal permeability in Crohn’s disease relatives

Subject ID: BR- └─┴─┴─┴─┘ └─┴─┘ Date (today)

_____/____/____

Yes

No

Yes

No

Yes

No

Yes

No

If No subject is NOT eligible If No subject is NOT eligible If Yes subject is NOT eligible

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Subject is declared full Relative of the Proband Subject is between 10-45 years old Subject is diagnosed with diabetes Subject is diagnosed with Celiac disease, Inflammatory Bowel Disease (IBD), or Irritable Bowel Syndrome (IBS) Significant symptoms of GI disease

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Part 2- Inclusion/Exclusion Criteria

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Year/ Month/ Day

Yes

No

If Yes subject is NOT eligible

*As per symptom questionnaire below If Yes subject is NOT eligible

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If not eligible patient forms will not be submitted to National Project Coordinating Office or to Database. All will be discarded within 3 months of determining subject is not eligible.

SUBJECT SCREENING & DEMOGRAPHICS

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ACCEPTED MANUSCRIPT SUBJECT SCREENING AND REGISTRATION QUESTIONNAIRE

Capsule endoscopy for the assessment of abnormal intestinal permeability in Crohn’s disease relatives

Subject ID: BR- └─┴─┴─┴─┘ └─┴─┘ Date (today)

_____/____/____

Part 3- Symptoms Review Questionnaire:

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Year/ Month/ Day

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Yes No 1. Are you in usual good health? 2. Have you ever been diagnosed with Yes No If No go to question 4 any chronic or recurring gastrointestinal disease or bowel disease? 3. What type of bowel disease do you _____________________ have? 4. Have you ever had stomach or Yes No bowel surgery? 5. Have you recently and Yes No If No go to question 9 unintentionally lost weight? 6. If yes, how much weight have you _____________ (lb)(kg) lost? 7. If yes, was this weight loss planned? Yes No 8. Was the unintentional weight loss in Yes No If Yes subject is not eligible the last 3 months more than 15% of your baseline weight? 9. Are you pregnant? Yes No If No go to question 11 10. If yes, what is the approximate due ____/____/____ YEAR /MONTH/DAY date? Yes No If No go to question 13 11. Do you usually have belly pain more than once a week? 12. Has this belly pain occurred more Yes No If Yes subject is not eligible than once per week for longer than 3 months in the past year? 13. Do you have liquid diarrhea more Yes No If No go to question 15 than 3 times per day? 14. If yes, has the diarrhea (>3 times per Yes No If Yes subject is not eligible day) been occurring for more than 3 months in the last year? 15. Do you have blood in your stool Yes No If Yes subject is not eligible with most stools? 16. Are you experiencing any illness or Yes No infection today?

SUBJECT SCREENING & DEMOGRAPHICS

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ACCEPTED MANUSCRIPT SUBJECT SCREENING AND REGISTRATION QUESTIONNAIRE

Capsule endoscopy for the assessment of abnormal intestinal permeability in Crohn’s disease relatives

Subject ID: BR- └─┴─┴─┴─┘ └─┴─┘ Date (today)

_____/____/____ Year/ Month/ Day

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17. Do you have a diagnosed Yes No If Yes subject is not eligible swallowing disorder or often have trouble with food getting stuck after you swallow it? 18. Do you experience abdominal pain, Yes No abdominal distension, or vomiting after meals? 19. Do you use anti-inflammatory Yes No If No go to question 21 medications known as NSAIDs (eg. Ibuprofen or Aspirin) on a regular basis? 20. If yes, how many times per week? _____________________ 21. Have you been diagnosed with heart Yes No If Yes subject is not eligible disease, COPD (chronic obstructive pulmonary disease), emphysema, or other significant lung disease, kidney failure, liver failure, or cancer? 22. Do you have a cardiac pacemaker or Yes No If Yes subject is not eligible implantable defibrillator device? 23. What medical conditions have you been diagnosed with by a physician?

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24. What medications do you take on a regular basis?

Subject is eligible for the study

SUBJECT SCREENING & DEMOGRAPHICS

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Yes

No

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ACCEPTED MANUSCRIPT SUBJECT SCREENING AND REGISTRATION QUESTIONNAIRE

Capsule endoscopy for the assessment of abnormal intestinal permeability in Crohn’s disease relatives

Subject ID: BR- └─┴─┴─┴─┘ └─┴─┘ Date (today)

_____/____/____

Registration Completed:

Date:

____/____/_____ Year

day

__________________________

PRINT

SIGNATURE

Research Coordinator

Principle Investigator

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Designation:

month

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By: _____________________

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Year/ Month/ Day

Subject Eligible and Accepted to participate in Study: By: ___________________

No

________________________ Principal Investigator Signature

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Print

Yes

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Full Exclusion Criteria 1) Known history of IBD, CD, ulcerative colitis, celiac disease, small bowel lymphoma or other small bowel cancer, radiation enteritis or previous abdominal

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radiation, gastroparesis, swallowing disorder or dysphagia.

2) Symptoms suggestive of IBD (chronic diarrhea > 3x per day for more than 3

months, blood in the stool with most stools, chronic abdominal pain > 1x per

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week for longer than 3 months, unintentional weight loss of more than 15% in the

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last 3 months, unexplained fevers, extra-intestinal manifestations of IBD). 3) Obstructive symptoms (bloating, abdominal distension, early satiety, nausea, abdominal pain related to meals and/or relieved by vomiting). 4) Previous luminal GI surgery (gastric, small bowel, colonic resection).

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5) NSAID or aspirin usage within the previous 2 months. 6) Cardiac pacemaker or implantable defibrillator.

7) Ongoing medical treatment of any inflammatory condition using anti-TNF

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antibody therapy, prednisone, methotrexate or azathioprine/6-MP. 8) Any other significant co-morbid illnesses that could affect the results or safety of

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capsule endoscopy (e.g. heart failure, cirrhosis, advanced coronary artery disease, advanced chronic obstructive pulmonary disease, renal failure, cancer).

9) Pregnancy.

10) Diabetes requiring medications.