Pan-enteric Capsule Endoscopy in Crohn's Disease: Impact on Therapeutic Decisions and Inter-observer Agreement in a Multicentre Case-based Study

Background and study aims Pan-enteric capsule endoscopy (CE) provides a comprehensive mucosal assessment of both the small bowel and colon in Crohn’s disease (CD). However, its incremental impact on structured clinical decision-making and inter-observer agreement remains insufficiently defined. We aimed to evaluate whether the availability of CE findings influences therapeutic decisions, risk stratification and monitoring strategies in patients with CD. Patients and methods We performed a multicentre, retrospective, paired case-based study including 50 real-world CD cases (35 adults, 15 paediatric). For each case, two anonymised vignettes were generated: one incorporating clinical, biochemical and cross-sectional imaging data without CE, and one additionally including CE findings. Ten experienced inflammatory bowel disease (IBD) gastroenterologists (six adult, four paediatric) independently reviewed all vignettes in randomised order using a structured questionnaire. The primary outcome was change in therapeutic decision-making after disclosure of CE findings. Secondary outcomes included changes in risk stratification, assessment of treatment efficacy, timing of follow-up, confidence in decision-making and inter-observer agreement. Results Access to CE findings significantly modified risk assessment and treatment selection. Overall, 53.3% of risk-stratification responses and 56.7% of treatment decisions changed, with a consistent shift towards higher perceived risk and treatment escalation (p < 0.0001 for both). CE also altered monitoring strategies, increasing reliance on endoscopic/CE-based assessment (change rate 36.7%; p < 0.0001), and modestly shortened planned follow-up intervals (change rate 18.5%; p = 0.0366). Confidence scores showed no significant overall shift (p = 0.2700), despite 41.6% of individual ratings changing. Inter-observer agreement improved from fair to moderate across several domains when CE results were available. No cases with isolated colonic CD were included in the final case set, and no capsule retention occurred in the included cohort. Conclusions In this multicentre paired case-based study, pan-enteric CE substantially influenced risk stratification, treatment selection and monitoring plans in CD, while improving inter-observer agreement across several decision domains. These findings indicate that CE meaningfully affects structured clinical decision-making in selected patients, particularly when small-bowel involvement is suspected or when conventional investigations are discordant. Prospective longitudinal studies are needed to determine whether CE-guided decisions translate into improved clinical outcomes.