Wireless capsule endoscopic detection of Meckel's diverticulum after nondiagnostic surgery

Meckel's diverticulum discovered by capsule endoscopy: a systematic review of case reports

OBJECTIVES

Capsule endoscopy has achieved its place as a diagnostic tool in a clinical setting, especially in the small bowel. The most frequent malformation of the gastrointestinal tract (Meckel's Diverticulum) has therefore been discovered incidentally by capsule endoscopies multiple times. However, it is still not a regular diagnostic modality when the pathology is suspected. In this review of case reports, we aim to evaluate the knowledge and rationales of using capsule endoscopy as a diagnostic tool for Meckel's diverticulum.

METHODS

We performed a search through Pubmed and Embase to find all publications describing cases of Meckel's diverticulum diagnosed by capsule endoscopy. All data was collected, and a stratification based on age group (adult versus pediatric patients) was performed.

RESULTS

The search resulted in 43 cases of Meckel's diverticulum diagnosed with capsule endoscopy, reported in 33 publications. The majority of the patients were male, with a median age of 20 years, and had an average of three negative investigations performed prior to capsule endoscopy. The three most commonly used investigations were upper and lower endoscopy and Meckel's scan. The most frequent finding on capsule endoscopy was the double lumen sign.

CONCLUSION

The case reports indicate that capsule endoscopy can and has been used as a diagnostic tool for Meckel Diverticulum going back as far as 2002, with the most common finding being the double lumen sign. But it also highlights that patients too often go through multiple negative investigations before having a capsule endoscopy performed.

Meckel's diverticulum diagnosed by double‐balloon enteroscopy: A single‐center retrospective study in Taiwan

Background and Aim

Meckel's diverticulum (MD) is a common congenital abnormality of the gastrointestinal (GI) tract. Although a few patients with MD present symptoms, preoperative diagnosis of MD is a clinical challenge because of its endoscopic inaccessibility. The aim of the present study was to investigate patients with MD diagnosed by double‐balloon enteroscopy (DBE) in Taiwan.

Methods

We conducted a retrospective study in a tertiary referral center in middle Taiwan. The clinical characteristics, endoscopic features, histopathological findings, treatment methods, and outcomes of patients with MD diagnosed by DBE were analyzed.

Results

A total of 14 male patients with MD diagnosed by DBE were enrolled. The mean age of all patients was 32.3 years. GI bleeding (78.6%) accounted for the major indication of DBE, followed by abdominal pain and Crohn's disease follow‐up. The mean distance between the ileocecal valve and MD was 68.9 cm. The average length of 12 patients with surgically resected MD was 5.2 cm. The diagnostic yields of the other modalities excepting DBE are as follows: capsule endoscopy, 50%; Meckel's scan, 11.1%; computed tomography, 16.7%; small bowel series, 0%; and angiography, 33.3%. MD presented as a large ostium in 13 patients (92.9%), a small ostium in 1 patient (7.1%), and bleeding signs in 10 patients (71.4%). Twelve patients (85.7%) underwent surgical treatment and 2 patients (14.3%) received conservative treatment. Heterotopic gastric tissue was identified in 4 patients (28.6%).

Conclusion

The present study showed that DBE is a more powerful modality in detecting MD than the other conventional modalities in Taiwan.

Meckel's Diverticulum Diagnosed by Balloon-Assisted Enteroscopy: A Multicenter Report from the Taiwan Association for the Study of Small Intestinal Diseases (TASSID)

BACKGROUND AND AIMS

Patients with Meckel's diverticulum (MD) are difficult to preoperatively diagnose because of its endoscopic inaccessibility. Balloon-assisted enteroscopy (BAE) allows endoscopic access to the entire small intestine. The aim of the current study was to investigate patients with MD diagnosed by BAE in Taiwan.

METHODS

We conducted a retrospective, multicenter study of patients with MD who were diagnosed by BAE in Taiwan. The clinical characteristics, endoscopic features, histopathological findings, treatment methods, and outcomes were analyzed.

RESULTS

A total of 55 patients with MD were enrolled (46 males and 9 females). The mean age at diagnosis was 34.1 years. Overt gastrointestinal bleeding (87.3%) was the primary indication for BAE, followed by abdominal pain (9.1%), suspected small bowel tumor (1.8%), and Crohn's disease follow-up (1.8%). The mean distance between the ileocecal valve and MD was 71.6 cm (regarding diagnostic yields: BAE-100%, capsule endoscopy-40%, Meckel's scan-35.7%, computed tomography-14.6%, small bowel series-12.5%, and angiography-11.1%; regarding endoscopic features of MD: a large ostium-89.1%, a small ostium-7.3%, and a polypoid mass-3.6%). Surgical treatment was performed in 76.4% patients, and conservative treatment was performed in 23.6% patients. The mean length of MD in 42 patients who underwent surgical resection was 5.2 cm (in 43 patients of MD with available histopathology: heterotopic gastric tissue, 42.4%, heterotopic gastric and pancreatic tissues, 7%; heterotopic pancreatic tissue, 4.7%; heterotopic colonic tissue, 2.3%; and a neuroendocrine tumor, 2.3%).

CONCLUSIONS

The current study showed BAE is a very useful modality for detecting MD compared with other conventional modalities.

Capsule endoscopy as a diagnostic test for Meckel's diverticulum

OBJECTIVE

We described a case series of patients diagnosed with Meckel's diverticulum using capsule endoscopy (CE), reviewed the literature, and aimed to reveal the common CE characteristics of Meckel's diverticulum.

MATERIALS AND METHODS

We reviewed a case series of Meckel's diverticulum in the Department of Gastroenterology, Beijing Shijitan Hospital Affliated to the Capital Medical University. In each case, primary upper endoscopy and colonoscopy failed to reveal a reason to explain the complaints (hematochezia in three cases and abdominal pain in one). CE (Pillcam SB2, Given Imaging, Yoqneam, Israel) was chosen as the next diagnostic test of choice and Meckel's diverticulum was detected by CE. Then, endoscopic characteristics and follow-up of Meckel's diverticulum were analyzed.

RESULTS

4 patients were enrolled. CE revealed Meckel's diverticulum in patients with different features. In case 1, CE revealed a typically double lumen sign and diaphragm sign, with visible blood. In case 2 and case 3, CE revealed a protruding lesion with/without erosion. In case 4, CE revealed multiple caved lesions, double lumen sign and capsule retention in an abnormal blind end for over 2 hours.

CONCLUSION

Except double lumen sign, partial disappearance of normal mucosa and capsule retention, other CE findings could be used for the diagnosis of Meckel's diverticulum, such as protruding lesion, caved lesion, solitary polyp and stenosing lesion.

Meckel's diverticulum diagnosis by video capsule endoscopy: A case report and review of literature

BACKGROUND

Meckel's diverticulum (MD) occurs predominantly in children and adolescents. It is rarely diagnosed in adults. Preoperative diagnosis is difficult due to low sensitivity of the radiological imaging studies. The role of video capsule endoscopy (VCE) in the diagnosis of MD is unknown, and the endoscopic patterns are not defined. We will describe four of our cases of MD evaluated with VCE and make a review of the literature focusing on the endoscopic characteristics.

CASE SUMMARY

We present four cases of MD confirmed by surgery. They were all adult males with ages going from 18 to 50 years, referred to our service from 2004 to 2018, due to obscure gastrointestinal bleeding (OGIB). They had a history of 1 mo to 10 years of overt and occult bleeding episodes. Laboratory blood test showed an iron-deficiency anemia from 4 to 9 g/dL of hemoglobin that required multiple hospitalizations and blood transfusions in all cases. Repeated upper digestive endoscopies and colonoscopies were negative. Small bowel was examined with VCE, which revealed double lumen images in all cases, one with polyps and three with circumferential ulcers in the diverticulum. However, based on VCE findings, preoperative diagnosis of MD was suggested only in two patients. Capsule was retained in one patient, which was recovered with surgery. The anatomopathological report revealed ulcerated ectopic gastric mucosa in all cases.

CONCLUSION

VCE is useful for the diagnosis of MD. However, endoscopic characteristics must be recognized in order to establish preoperative diagnosis.

Specific characteristics of hemorrhagic Meckel's diverticulum at double-balloon endoscopy

Background and study aims Diagnosis of Meckel's diverticulum (MD) before surgery may be challenging; double-balloon endoscopy (DBE) facilitates identification of MD in the setting of a gastrointestinal bleeding; however, MD can be found incidentally without this condition. The purpose of this research was to determine specific characteristic of hemorrhagic MD and incidental MD at DBE. Patients and methods Ectopic gastric mucosa enclosed in the MD and/or ulceration were defined as "major findings"; ring-like scar surrounding the MD was defined as "minor finding". We retrospectively reviewed the medical records of patients affected by MD and analyzed the findings that significantly affected the characterization of MD. Results MD was diagnosed in 33 patients. The axis of the diverticulum was longer in hemorrhagic MD compared to incidental MD (P = 0.031). The amount of transfusion was significantly higher (P = 0.018) in the hemorrhagic MD group. Hemorrhagic MD was significantly more correlated with major findings (P = 0.01) and minor findings (P < 0.01). The specificity of major finding was 100 % while the sensitivity of major and/or minor findings was 96 %. Conclusions The combination of major and minor findings appears to improve the diagnostic ability of hemorrhagic MD avoiding unnecessary diverticulectomy.

Diagnosis of Bleeding Meckel's Diverticulum in Adults

BACKGROUND AND AIMS

Various modalities have been used to diagnose Meckel's diverticulum (MD) in practice, but with their diagnostic accuracy deemed to be unsatisfactory for clinical practice. Moreover, the usefulness of these modalities has not been evaluated for the diagnosis of bleeding MD in adults, due to the relative rarity of this condition. Therefore, the aim of our multicenter study was to determine the most accurate modality for the preoperative diagnosis of bleeding MD in adults.

METHODS

We conducted a retrospective analysis of the diagnostic accuracy for small bowel bleeding associated with MD of different modalities in patients ≥18 years old who underwent assessment for MD, with confirmation at the time of explorative surgery. Diagnostic accuracy of the different modalities was evaluated against the diagnosis obtained using technetium-99m pertechnetate scintigraphy (also known as Meckel's scan), considered to be the gold standard for the diagnosis of bleeding MD in pediatrics.

RESULTS

Thirty-five adults were identified with bleeding in MD over the study period, between 2005 and 2012. Among these patients, only 24 (68.6%) were diagnosed with MD preoperatively. The mean (95% confidence interval) diagnostic accuracy of selected modalities was as follows: Meckel's scan, 21.4% (5.7%-51.2%); capsule endoscopy, 35.7% (14.0%-64.4%); balloon-assisted enteroscopy (BAE), 85.0% (61.1%-96.0%); angiography, 0.0% (0.0%-80.2%); computed tomography, 31.8% (14.7%-54.9%); and small-bowel follow-through, 62.5% (25.9%-90.0%). The diagnostic accuracy was significantly higher for BAE than for Meckel's scan (P = 0.001).

CONCLUSIONS

Among available diagnostic modalities, BAE provides the highest accuracy for the diagnosis of bleeding MD in adults and, therefore, should be considered as the preferred modality for preoperative diagnosis.

Capsule endoscopy is useful diagnostic tool for diagnosing Meckel's diverticulum

OBJECTIVE

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. Although a majority of patients remain asymptomatic, complications may occur in a subset of patients. MD is a rare cause of gastrointestinal bleeding (GIB) in adults. We aimed to clarify the possible role of capsule endoscopy (CE) in the identification of Meckel's diverticulum.

PATIENTS AND METHODS

From October 2004 to December 2010, 157 CEs were performed (83 male individuals, mean age 51±20 years; range 3-83 years) for obscure GIB. Before CE, all patients underwent nonconclusive upper and lower endoscopy at least two times and barium follow-through.

RESULTS

CE identified the source of bleeding in 70/157 patients (44.6%). MD was diagnosed in 13/70 (18.6%) patients (11 male individuals, mean age 35±20 years, range, 3-69 years) after CE. Nine patients presented with obscure overt and four with obscure occult bleeding. The mean duration of obscure GIB history was 13 months (range 1-72 months). The mean hemoglobin concentration at the time of the procedure was 115±12 g/l. The findings of MD on CE were double lumen sign (13/13), visible blood (7/13), and diaphragm sign (6/13). All patients were operated upon, and MD histologically verified in 11. In two patients CE was false-positive and in two patients, false-negative. Capsule endoscopy had a positive predictive value of 84.6% for the diagnosis of MD.

CONCLUSION

MD should be considered in the differential diagnosis of obscure GIB in adults. CE is an effective and promising modality for diagnosing MD in patients with obscure GIB.

Imaging of Meckel's diverticulum in adults: pictorial essay

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. It is usually asymptomatic but may present with complications of acute diverticular inflammation, ulceration, hemorrhage, small bowel obstruction, perforation, retained foreign bodies, enterolith formation, and neoplasm development. Thus, the preoperative radiological diagnosis is crucial for proper management of the patients. This article reviews the anatomic and clinical features of Meckel's and describes the role of imaging in the detection of Meckel's and evaluation of its associated pathological processes.

Radionuclide small intestine imaging

The aim of this overview article is to present the current possibilities of radionuclide scintigraphic small intestine imaging. Nuclear medicine has a few methods-scintigraphy with red blood cells labelled by means of (99m)Tc for detection of the source of bleeding in the small intestine, Meckel's diverticulum scintigraphy for detection of the ectopic gastric mucosa, radionuclide somatostatin receptor imaging for carcinoid, and radionuclide inflammation imaging. Video capsule or deep enteroscopy is the method of choice for detection of most lesions in the small intestine. Small intestine scintigraphies are only a complementary imaging method and can be successful, for example, for the detection of the bleeding site in the small intestine, ectopic gastric mucosa, carcinoid and its metastasis, or inflammation. Radionuclide scintigraphic small intestine imaging is an effective imaging modality in the localisation of small intestine lesions for patients in whom other diagnostic tests have failed to locate any lesions or are not available.

Bleeding Meckel's diverticulum diagnosed and treated by double-balloon enteroscopy

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract. The diagnosis of symptomatic MD has been cumbersome. Several case reports been published regarding direct visualization of MD with double balloon enteroscopy (DBE); diagnosing a bleeding MD leading to surgical resection. We report the use of DBE for the treatment of a bleeding MD.

Wireless Capsule Endoscopy Detects Meckel's Diverticulum in a Child with Unexplained Intestinal Blood Loss

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract, affecting about 2% of the population. Most cases of Meckel's diverticula are asymptomatic. The diagnosis of symptomatic MD is often difficult to make. We report the case of an 8-year-old boy who presented with GI bleeding due to MD. The diagnostic difficulties after an initial negative endoscopic evaluation and the diagnostic value of the various endoscopic procedures are discussed. The patient had suffered from bright red stools for 20 h before hospital admission. GI scintigraphy with ^99mTc-Na-pertechnetate was negative for heterotopic gastric tissue in the small bowel area. Colonoscopy performed in order to exclude Crohn's disease was also negative. He was placed on ranitidine at a dose of 6 mg/kg body weight twice daily. The patient remained asymptomatic over a period of 6 months before he was readmitted due to macroscopic rectal bleeding. Upper endoscopy and colonoscopy used to investigate the source of bleeding showed normal macroscopic findings. Radiolabeling of blood constituents with ^99mTc on delayed imaging showed radionucleotide concentration in the ascending and transverse colon suggestive of a lesion in the ileocecal area. Further investigation with the use of wireless capsule endoscopy revealed a MD. Wireless capsule endoscopy may thus be indicated for patients with GI blood loss when other diagnostic methods, such as upper and lower endoscopy and colonoscopy, have failed to identify the source of bleeding.

Endoscopic observation of Meckel's diverticulum by double balloon endoscopy: report of five cases

BACKGROUND AND AIM

Most cases of Meckel's diverticula are asymptomatic, however, some cases presented with gastrointestinal (GI) bleeding. It is often difficult to determine whether Meckel's diverticulum is a source of obscure GI bleeding. Double balloon endoscopy allows endoscopic access to the entire small intestine. The aim of this study was to compare endoscopic findings of three hemorrhagic and two non-hemorrhagic Meckel's diverticula in patients with obscure GI bleeding using this novel technique.

METHODS

Between September 2000 and April 2005, 354 enteroscopies, including 162 anterograde and 192 retrograde procedures, were performed on 217 patients at the Jichi Medical University Hospital, Japan, using the double balloon endoscopy system. Five consecutive patients where Meckel's diverticulum was endoscopically observed were selected and analyzed.

RESULTS

Double balloon endoscopy enabled direct observation of Meckel's diverticula in all five patients. Surgical procedures were indicated for three patients where double balloon endoscopy discovered ulcers. By contrast, double balloon endoscopy detected other sources of bleeding in the remaining two patients where no ulcers were found in the Meckel's diverticula.

CONCLUSION

Endoscopic observation of the ulcers in Meckel's diverticula was important evidence of bleeding in patients with obscure GI bleeding. Other sources of bleeding should be considered when no ulcers are found in the Meckel's diverticula.

Possible Role of Meckel's Scan Fused with SPECT CT Imaging: Unraveling the Cause of Abdominal Pain and Obscure-Overt Gastrointestinal Bleeding

A 27-year-old male presented with recurrent abdominal pain and high volume hematochezia despite undergoing extensive testing and a right hemicolectomy 3 years prior for a linear bleeding ulceration in the ascending colon. Studies at the University of Michigan included esophagogastroduodenoscopy (EGD), colonoscopy and video capsule endoscopy (VCE), revealing an arteriovenous malformation (AVM) in the terminal ileum. He was hospitalized for recurrent symptoms. His presentation suggested a small bowel source of obscure-overt GI bleeding based on prior non-diagnostic colonoscopy and EGD and a bilious nasogastric lavage. Tagged red blood cell scan localized bleeding to the right lower quadrant. Colonoscopy showed fresh blood in the terminal ileum without a clear source. Angiography showed no evidence of bleeding or terminal ileal AVM. A novel Meckel's scan fused with SPECT imaging showed focal uptake in the terminal ileum. The patient underwent Meckel's diverticulectomy with sparing of adjacent bowel and has remained asymptomatic for 19 months. This case illustrates that patients with obscure-overt GI bleeding require a step-wise multi-modality diagnostic work-up. Because Meckel's scans are false-positive in 28% of adults, Meckel's scan fused with SPECT imaging may offer an approach to refine diagnostic accuracy of either scan alone, but requires further investigation. Exploratory laparotomy should be reserved as a last option and is best performed with intraoperative endoscopy.

Reproducibility of wireless capsule endoscopy in the investigation of chronic obscure gastrointestinal bleeding

BACKGROUND

Capsule endoscopy (CE) is a valuable tool in the diagnostic evaluation of obscure gastrointestinal bleeding, but limited information is available on the reproducibility of CE findings.

OBJECTIVE

To compare two successive CE studies with push enteroscopy (PE) in patients presenting with chronic obscure gastrointestinal bleeding.

METHODS

A prospective study was conducted. Ten patients (seven men and three women) with chronic obscure gastrointestinal bleeding and no contraindications for CE were eligible and completed the trial. For each patient, the first capsule was administered on day 1, the second capsule was administered on day 2 and PE was performed on day 3. Endoscopists were blinded to the capsule findings. Capsule findings were assessed independently by two investigators blinded to PE findings.

RESULTS

A potential small intestinal bleeding source was found in 60% of the patients when all the studies were combined. A bleeding source was found in four patients in both CE studies. The second CE also identified a bleeding source in a fifth patient. Interobserver agreement by kappa analysis was 0.642 to 1.000 (P < or 05) for the CE studies. PE identified a potential small bowel bleeding site in four patients, including one patient who had negative CE studies.

CONCLUSIONS

This study confirmed the reproducibility of CE findings on successive studies. Some patients did not have a source of bleeding in the small intestine, and all studies found this.

Current management of umbilical abnormalities and related anomalies

Prenatally, the umbilicus is of paramount importance, providing the gateway between the mother and the fetus. As the fetus becomes increasingly autonomous at the end of the second month of fetal life, the connections (vitelline, urachal) diminish in significance and involute. Disturbances in this process can result in a wide variety of abnormalities, ranging from relatively minor defects identified at birth (umbilical granulation tissue) to life-threatening complications quiescent until late adulthood (urachal carcinoma). This section will review the 'state of the art' in evaluation and management of these umbilical and related abnormalities.

Ileus secondary to wireless capsule enteroscopy

Wireless capsule enteroscopy, being a novel, painless investigative technique, is reported to be significantly superior to push enteroscopy in its ability to find bleeding abnormalities in the small intestine. Here we report a case of acute jejunal obstruction following wireless capsule endoscopy. The patient had a 1-month history of gastrointestinal bleeding of unknown source. Further evaluation including gastroscopy and colonoscopy, angiography and computed tomography (angio-CT), and radio-labeled erythrocytes scan failed to reveal a source of bleeding. Therefore, wireless capsule enteroscopy was performed. Before capsule endoscopy, there was no clinical or imaging evidence of strictures or stenosis. At readmission it could be shown that there were two inflamed strictures of the small intestine. The capsule was detected at a stricture of the small intestine detected by abdominal ultrasonography and conventional computed tomography. The patient underwent a medical treatment with steroidal and other anti-inflammatory drugs for a total of 23 days and was discharged without complaints. Acute laparotomy after readmission with jejunal ileus proofed the capsule occluding two highly inflamed jejunal stenosis caused by Crohn disease. The present case demonstrates the potential for complications when wireless capsule enteroscopy is performed in the presence of intestinal strictures. Any history of inflammatory bowel disease, abdominal irradiation, cancer, obstruction, and abdominal surgery must be elicited in detail and may exclude the use of wireless capsule enteroscopy.

Push-and-pull enteroscopy using the double-balloon technique (double-balloon enteroscopy) for the diagnosis of Meckel's diverticulum in adult patients with GI bleeding of obscure origin

BACKGROUND

Meckel's diverticulum (MD) occurs in 2-3% of the population. Although the clinical, histopathologic, and radiologic features of the complications of MD are well known, the diagnosis may be difficult before surgery.

CASE REPORT

Three patients (age 22-34 yr, two women) presenting with gastrointestinal (GI) bleeding of obscure origin underwent multiple endoscopic and radiologic tests including capsule endoscopy and Tc-99m pertechnetate scintigraphy before push-and-pull enteroscopy using a double-balloon technique (double-balloon enteroscopy). Double-balloon enteroscopy was performed in all three patients using oral and anal approaches to evaluate the entire intestine. In one case, MD was detected using the oral route; the diagnosis was confirmed using the anal approach. In two patients, the lumen of MD was disclosed using the anal route. No procedure-related complications occurred. Push-and-pull enteroscopy was the only nonsurgical procedure that provided a precise diagnosis. All patients underwent surgical resection of the diverticulum. In one case, ectopic gastric tissue was found histologically. No further bleeding occurred during follow-up (6-9 months).

CONCLUSIONS

Keeping the low sensitivity of Tc-99m scintigraphy in the adult population in mind, double-balloon enteroscopy might be the modality of choice in young adult patients with acute recurrent GI bleeding of obscure origin and a suspected diagnosis of MD.

Contraindications to capsule endoscopy: do any still exist?

In patients requiring WCE most contraindications are relative and the procedure can be performed safely in almost all clinical settings. The only true remaining contraindications to capsule endoscopy are obstruction/pseudo-obstruction and pregnancy. Informed consent of the risks and benefits, including NNE, should be discussed with all patients undergoing WCE examination.

The role of PillCam endoscopy in Crohn's disease: the European experience

The European experience of wireless capsule endoscopy (WCE) inCrohn's disease (CD) is presented. Evidence from prospectivestudies comparing WCE with standard methods speaks in favor ofWCE as the method with the highest sensitivity for diagnosingsmall intestinal CD. WCE is likely to be helpful in diagnosing CD,in determining the extent of the disease, and in providing infor-mation on which of the current treatment approaches are specifi-cally effective within the small intestine. Although the invention ofthe patency capsule was helpful for diagnosing and characterizingsmall bowel strictures, the problem of capsule retention in CDpatients remains a controversial issue.

Laparoscopy-assisted surgical management of obscure gastrointestinal bleeding secondary to Meckel's diverticulum in a pediatric patient: case report and review of literature

Despite advances in endoscopy and imaging, acute gastrointestinal (GI) bleeding of obscure origin in children presents a challenge to pediatric gastroenterologist. Bleeding Meckel's diverticulum (MD) commonly presents with acute episode of lower GI bleeding. A conventional diagnostic algorithm includes endoscopy, technetium 99m pertechnetate scintigraphy, angiography, and exploratory laparotomy. The advent of minimal access surgery prompts the use of laparoscopy for children with obscure GI bleeding. Laparoscopy assists in the diagnosis and can offer definitive treatment of patients with MD. Herein, we report a case of pediatric GI bleeding of obscure origin associated with MD that was successfully diagnosed and managed via laparoscopy. This article updates the current management for pediatric patients with obscure GI bleeding and the role of laparoscopy in the management of MD.

Enteroscopy

Wireless capsule endoscopy and double-balloon endoscopy are new methods of enteroscopy that have been introduced in recent years. Wireless capsule endoscopy is an epoch-making examination method that makes possible an endoscopic imaging examination of the entire small intestine without discomfort and without confining patients to a medical facility. Although it is expected to be useful as an initial examination for finding diseases of the small intestine, it cannot be used for biopsy or treatment. One risk associated with the capsule endoscopy technique is entrapment by strictures. Double-balloon endoscopy is based on a new insertion technique in which two balloons, one at the distal end of the endoscope and the other at the distal end of an overtube, are operated in combination, and the endoscope is inserted while simultaneously shortening the intestine. It can be inserted through either the mouth or the anus, allowing the observation of the entire gastrointestinal tract. It features excellent maneuverability even in the distal small intestine, and enables back-and-forth observation, biopsy, and endoscopic treatment at any given site. These two new enteroscopy techniques are expected to lead to innovations in how diseases of the small intestine are approached.

Simethicone for small bowel preparation for capsule endoscopy: a systematic, single-blinded, controlled study

BACKGROUND

Capsule endoscopy is a new imaging method for visualization of the entire small bowel. However, no standardized protocol for bowel preparation for capsule endoscopy has been evaluated.

METHODS

Capsule endoscopy was performed in 36 consecutive patients, all of whom fasted for 12 hours before ingestion of the capsule. Before capsule endoscopy, 18 patients received 80 mg simethicone and 18 had no supplemental medication for bowel preparation. Two observers, both experienced endoscopists, independently reviewed the examinations in a single-blinded and randomly assigned fashion. Mucosal visibility and intraluminal gas bubbles were assessed and graded by both observers.

RESULTS

Bowel preparation with simethicone resulted in significantly better visibility because of fewer intraluminal bubbles (p<0.01). Interobserver agreement was excellent (r>/=0.8; k 0.78: 95% CI[0.57, 0.98] ). No adverse effect of simethicone was observed.

CONCLUSIONS

Simethicone may be added to the routine preparation for capsule endoscopy to improve the visibility of small bowel mucosa.