Wireless capsule video endoscopy compared to barium follow-through and computerised tomography in patients with suspected Crohn's disease--final report

Video capsule endoscopy of the small bowel

PURPOSE OF REVIEW

It is now over 8 years since small bowel capsule endoscopy (SBCE) was first introduced to the gastrointestinal community. The original capsule (Given Imaging, YoKneam, Israel) - a disposable 26 x 11 mm video capsule containing its own optical dome, light source, batteries, transmitter and antenna - is swallowed with water after a 12 h fast. The capsule is propelled via peristalsis through the gastrointestinal tract and is excreted naturally. We will review all recent work concerning SBCE.

RECENT FINDINGS

At present there are three other SBCEs in the market. SBCE has become a first-line tool to detect abnormalities in the small bowel, as all other imaging technologies are rather ineffective, or very tedious.Indications for SBCE include obscure gastrointestinal bleeding, suspected small bowel tumor, suspected Crohn's disease, surveillance of inherited polyposis syndromes, drug-induced small bowel injury or any abnormal small bowel imaging and new ones are emerging like small bowel motility. Since most of the articles in the literature relate to the PillCam small bowel capsule the data presented will refer mainly to this capsule endoscopy.

SUMMARY

SBCE has shed new light into our knowledge of the small bowel, paving the way for new modalities to come.

Capsule endoscopy in patients with Crohn's disease: diagnostic yield and safety

BACKGROUND

Capsule endoscopy (CE) is increasingly used in patients with suspected or known Crohn's disease (CD).

OBJECTIVE

To determine the diagnostic yield of CE and the distribution of small-bowel (SB) lesions in symptomatic patients with known CD.

DESIGN AND SETTING

Retrospective review of CE procedures performed in patients with CD between 2001 and 2005 in a tertiary care center.

PATIENTS

One hundred thirty-four patients with an established diagnosis of CD and symptoms suggestive of active disease.

INTERVENTIONS

Swallowing the capsule.

MAIN OUTCOME MEASUREMENTS

Diagnostic yield of CE and distribution of SB lesions in patients with CD.

RESULTS

One hundred forty-six CE procedures were performed on 134 CD patients. Fifty-two (39%) of 134 patients had CE findings diagnostic of active CD (> 3 ulcerations), and 17 (13%) had findings suggestive of active CD (< or = 3 ulcerations). Fifty-seven (42%) patients had normal findings, and 6% had normal but incomplete studies. The distribution of SB lesions was 32% in the duodenum, 53% in the jejunum, 67% in the proximal ileum, and 85% in the distal ileum. CE was comparable to ileoscopy in detecting ileal ulcerations (55% vs 48%), but superior to SB follow-through in detecting CD lesions in the SB (incremental yield of 32%; 95% CI, 9%-54%; P = .0017).

LIMITATIONS

Retrospective study from a single center.

CONCLUSIONS

CE identified SB lesions in approximately half of symptomatic CD patients. Large-scale prospective studies are needed to evaluate whether positive CE findings may affect disease outcomes.

The role of capsule endoscopy in small bowel Crohn's disease

Video capsule endoscopy is an invaluable tool for examining the small bowel. It is non-invasive and generally well tolerated, however its role in the assessment of the severity and extent of small bowel Crohn's disease has not, to date, been adequately evaluated.

METHODS

All capsule endoscopies performed over a two year period in a tertiary referral centre in subjects with known or suspected Crohn's disease were reviewed.

RESULTS

Twenty-six capsule endoscopy studies in total were included. These were performed in 15 cases of known Crohn's disease, 5 cases of suspected Crohn's disease, 3 cases of endoscopically diagnosed non-specific terminal ileal inflammation and finally 3 post colectomy cases of indeterminant being considered for IPAA formation. Ten patients known to have small bowel Crohn's disease were prospectively recruited; of 3 with normal small bowel follow through or CT exams, one had an abnormal capsule endoscopy. The other 7 patients had small bowel follow through or abdominal CT scans consistent with small bowel Crohn's disease; additional mucosal abnormalities were detected by capsule endoscopy in 6 cases with capsule retention in the stomach in one. Of 5 with colonic Crohn's disease normal small bowel imaging corresponded with normal capsule endoscopy in all but one. A diagnosis of Crohn's disease was made in 2 out of 5 cases of suspected Crohn's disease on the basis of the capsule endoscopy findings. Three patients with non-specific acute terminal ileal inflammation at ileocolonoscopy were confirmed to have ongoing inflammation. The capsule was retained in four subjects beyond 24 h.

CONCLUSION

Capsule endoscopy more accurately determines the severity and extent of the Crohn's disease in the small bowel than traditional imaging modalities.

Comparison of capsule endoscopy with enteroclysis in the investigation of small bowel disease

PURPOSE

To compare results of capsule endoscopy with those of barium enteroclysis or CT enteroclysis.

METHODS

Retrospective review of hospital records revealed 65 patients who had an enteroclysis and small bowel capsule endoscopy. The diagnostic yield of capsule endoscopy was compared with the enteroclysis using Fisher's exact test.

RESULTS

The main indications were obscure gastrointestinal bleeding (n = 37) and suspected Crohn disease (n = 17). Radiologic studies included CT enteroclysis (n = 30), and fluoroscopic barium enteroclysis with carbon dioxide (n = 18) or with methylcellulose (n = 17). Capsule endoscopy had a higher diagnostic yield (8/17) compared to barium-methylcellulose cellulose enteroclysis (1/17) (P = 0.02). The diagnostic yield of capsule endoscopy was not significantly different compared with barium-carbon dioxide (12/18 vs. 10/18) enteroclysis or with CT enteroclysis (9/30 vs. 8/30). Vascular lesions were better assessed with capsule endoscopy. However, the CT enteroclysis found more lesions in patients with chronic abdominal pain.

CONCLUSION

Barium-carbon dioxide enteroclysis and CT enteroclysis have similar diagnostic yields for small bowel disease compared to capsule endoscopy. Barium methylcellulose has an inferior diagnostic yield.

Wireless capsule endoscopy in Italy: adding context-specific data to the review of the evidence from literature

OBJECTIVES

The aim of this study was to assess the evidence of diagnostic accuracy of the wireless capsule for endoscopy (WCE) for the diagnosis of obscure gastrointestinal bleeding (OGIB) and small bowel disease in adults and translate it to the context of the Italian National Health Service.

METHODS

We performed a systematic review of secondary and primary literature. We reviewed WCE diagnostic accuracy, safety, economic evaluations for OGIB. Context-specific data about WCE diffusion, costs, appropriateness of WCE use were collected by means of a national survey involving all Italian gastroenterological departments.

RESULTS

We updated the systematic review of the most recent health technology assessment report (2006). Our review shows lack of robust comparative evidence of diagnostic accuracy of WCE. The studies' design do not allow collection of reliable evidence due to the uncertainty surrounding morphological variability of bleeding vascular gut lesions. The national survey reported widespread WCE use and data on appropriateness and costs.

CONCLUSIONS

Evidence of WCE diagnostic accuracy is of low quality, and there is a requirement for randomized comparisons. Our findings raise the issue of technology governance and show the importance of an assessment before the technology being widely commercialized.

Comparison of capsule endoscopy with other imaging modalities in small bowel

Until only a few years ago, most of the small bowel was beyond the range of conventional examinations because of its special anatomical position. The advent of capsule endoscopy (CE) represents a significant breakthrough for non-invasive and visual diagnosis of diseases in the small bowel. Since CE permits direct acquisition of images from the mucosa with high sensitivity and safety, it has become an important tool for diagnosis and surveillance of obscure gastrointestinal bleeding, Crohn's disease, familial adenomatous polyposis and other small bowel diseases. However, CE also has some weakness such as low specificity and risk of retention. In this review, we will compare CE with other imaging modalities in small bowel.

Enteroscopy in the diagnosis and management of Crohn disease

Crohn disease is a chronic disorder that can affect any part of the gastrointestinal tract, and is characterized by mucosal and transmural inflammation of the bowel wall. The disease most commonly involves the small bowel. Evaluation of patients with suspected Crohn disease has traditionally involved the use of ileocolonoscopy, push enteroscopy, and barium small bowel radiography. A large proportion of patients with mild small bowel disease or involvement of the mid small bowel can potentially be missed if only these tests are utilized. Enteroscopy is defined as direct visualization of the small bowel using a fiber optic or wireless endoscope. Following recent advances in technology, enteroscopy currently plays a pivotal role not only in the diagnosis of small bowel Crohn disease but also in the management of its complications, such as bleeding and strictures. Enteroscopy may have additional roles in the future, including the objective assessment of mucosal response to therapy, and surveillance for small bowel malignancy. This article focuses on the utility of enteroscopy, and its advantages and limitations in the evaluation and longterm management of Crohn disease.

Abdominal surgery affects small bowel transit time and completeness of capsule endoscopy

The aim of the study was to evaluate bowel dysmotility in patients with a history of abdominal surgery by measuring both gastric transit time and small bowel transit time during capsule endoscopy and assessing the completeness of the examination. The study included 26 patients who had undergone abdominal surgery (postoperative group) and 52 patients who had not (control group). The capsule reached the cecum in 50.0% of the postoperative group and 80.8% of the control group (P=0.005). While there was no significant difference in gastric transit time between the two groups (P=0.882), small bowel transit time was significantly longer in the postoperative group (338.3+/-119.2 min) than in the control group (266.4+/-110.8 min, P=0.010). This is the first study to report that the small bowel transit time during capsule endoscopy is prolonged in patients who had a history of abdominal surgery, resulting in a lower frequency of complete examination.

Management of Crohn's disease in adults

Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When data that will withstand objective scrutiny are not available, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. Given the wide range of choices in any health-care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee. Expert opinion is solicited from the outset for the document. The quality of evidence upon which a specific recommendation is based is as follows: Grade A: Homogeneous evidence from multiple well-designed randomized (therapeutic) or cohort (descriptive) controlled trials, each involving a number of participants to be of sufficient statistical power. Grade B: Evidence from at least one large well-designed clinical trial with or without randomization, from cohort or case-control analytic studies, or well-designed meta-analysis. Grade C: Evidence based on clinical experience, descriptive studies, or reports of expert committees. The Committee reviews guidelines in depth, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time.

Quality, clinical influence and tolerance of computed tomography enteroclysis in patients with suspected small bowel disease

BACKGROUND

Computed tomography enteroclysis (CTE) may be superior to other small bowel imaging techniques, detecting subtle mucosal lesions and extraluminal pathology. This study aimed to define the technical success, clinical influence and tolerance of CTE in patients with suspected small bowel disease.

METHODS

CTE scans of 42 consecutive patients (aged 21-78 years, 12 men) were reviewed by a single radiologist for technical adequacy and diagnosis. A panel of gastroenterologists reviewed clinical information. At a telephone interview, tolerance of CTE was graded numerically from 1 (unbearable) to 10 (excellent) and descriptively as unbearable, fair, good or excellent.

RESULTS

Good or optimal distension of small bowel was achieved in 98%. The entire small bowel was imaged in 88%. Eighteen patients had a normal small bowel, whereas 12 (29%) had active small bowel Crohn disease, 4 intussusception, 3 small bowel diverticula and 7 having other diagnoses. Mesenteric lymphadenopathy was evident in 11 and fat stranding in 5. CTE resulted in a new or altered diagnosis in 13 (31%) patients and identified more extensive Crohn disease in a further 8 (19%). A change in management plan was instituted in 18 (43%) patients, with subsequent clinically significant improvement in 12. 33 (85%) described the procedure as 'fair' or 'unbearable' rather than 'good' or 'excellent'. The median tolerance score was 3 out of 10.

CONCLUSION

CTE provided high-quality images in nearly all patients and had an effect on diagnosis, management or outcome in most, but was not well tolerated.

Biochromoendoscopy: molecular imaging with capsule endoscopy for detection of adenomas of the GI tract

BACKGROUND

Current capsule endoscopy (CE) provides minimally invasive technology for GI imaging but has limited ability to discriminate different types of polyps. Near infrared fluorescent (NIRF) probes activated by biomarkers upregulated in adenomas (eg, cathepsin B) are potentially powerful tools to distinguish premalignant or malignant lesions from benign or inflammatory lesions.

OBJECTIVES

To examine whether CE can be integrated with NIRF probes to detect adenomas and whether cathepsin B-activated NIRF probes are activated by benign or inflammatory lesions.

DESIGN

Mouse models of adenomas, hyperplactic/lymphoid polyps, and acute or chronic intestinal inflammation were injected intravenously with a cathepsin B-activated probe (Prosense 680). Dissected intestine was imaged with CE under white or NIRF light. For NIRF excitation (680 nm), dichroic and emission (700 nm) filters were combined with CE when images were recorded. Prosense 680 samples with or without protease were used as positive and negative controls. CE-based imaging data were verified by using and independent imaging system (Xenogen IVIS system).

MAIN OUTCOME MEASUREMENTS

Proof of principal that CE integrated with NIRF probes can detect and discriminate adenomas from other lesions.

RESULTS

CE-based NIRF imaging with Prosense 680 readily visualized adenomas, including in the colitis model. NIRF signals of different intensities were detected. Prosense 680 was not activated by benign or inflammatory lesions.

LIMITATION

Optical filters external to the capsule were used.

CONCLUSIONS

We demonstrate proof of the principle that biochromoendoscopy-CE combined with molecular probes--provides a novel approach that differentiates adenomas from benign polyps and inflammatory lesions.

Small-bowel imaging in Crohn's disease: a prospective, blinded, 4-way comparison trial

BACKGROUND

With the introduction of new techniques to image the small bowel, there remains uncertainty about their role for diagnosing Crohn's disease.

OBJECTIVE

To assess the sensitivity and specificity of capsule endoscopy (CE), CT enterography (CTE), ileocolonoscopy, and small-bowel follow-through (SBFT) in the diagnosis of small bowel Crohn's disease.

METHODS

Prospective, blinded trial.

SETTING

Inflammatory bowel disease clinic at an academic medical center.

PATIENTS

Known or suspected Crohn's disease. Exclusion criteria included known abdominal abscess and non-steroidal anti-inflammatory drug (NSAID) use. Partial small-bowel obstruction (PSBO) at CTE excluded patients from subsequent CE.

INTERVENTIONS

Patients underwent all 4 tests over a 4-day period.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, and accuracy of each test to detect active small-bowel Crohn's disease. The criterion standard was a consensus diagnosis based upon clinical presentation and all 4 studies.

RESULTS

Forty-one CTE examinations were performed. Seven patients (17%) had an asymptomatic PSBO. Forty patients underwent colonoscopy, 38 had SBFT studies, and 28 had CE examinations. Small-bowel Crohn's disease was active in 51%, absent in 42%, inactive in 5%, and suspicious in 2% of patients. The sensitivity of CE for detecting active small-bowel Crohn's disease was 83%, not significantly higher than CTE (83%), ileocolonoscopy (74%), or SBFT (65%). However, the specificity of CE (53%) was significantly lower than the other tests (P < .05). One patient developed a transient PSBO due to CE, but no patients had retained capsules.

LIMITATION

Use of a consensus clinical diagnosis as the criterion standard-but this is how Crohn's disease is diagnosed in practice.

CONCLUSIONS

The sensitivity of CE for active small-bowel Crohn's disease was not significantly different from CTE, ileocolonoscopy, or SBFT. However, lower specificity and the need for preceding small-bowel radiography (due to the high frequency of asymptomatic PSBO) may limit the utility of CE as a first-line test for Crohn's disease.

Capsule endoscopy may reclassify pediatric inflammatory bowel disease: a historical analysis

BACKGROUND

Data are sparse on the role of capsule endoscopy (CE) in classifying disease type, affecting patient management, and altering health outcomes in pediatric inflammatory bowel disease (IBD). In a retrospective cohort analysis of symptomatic pediatric patients with previously diagnosed IBD, we evaluated whether data from CE would result in the recognition of new disease locations that could alter the current diagnosis and provide information to better manage the underlying disease.

PATIENTS AND METHODS

CE evaluation was performed in 28 patients an average of 4.2 +/- 3 years after original IBD diagnosis, and was prompted by exacerbation of underlying disease, growth failure/weight loss, or presurgical evaluation. Of the patients, 7 of 28 (25%) were originally diagnosed as having ulcerative colitis (UC) (n = 5) or indeterminate colitis (IC) (n = 2), while 21 of 28 (75%) were diagnosed as having Crohn disease (CD).

RESULTS

Following CE examination, 4 of 5 patients with UC and 1 of 2 patients with IC (total 5 of 7, 71% of UC/IC patients) had their disease reclassified to CD based upon newly diagnosed small bowel mucosal lesions. Moreover, 13 of 21 (62%) patients with CD were found at the time of CE examination to have more extensive small bowel disease with newly diagnosed jejunal disease found in 12 of 13 (92%) patients. In the 5 newly diagnosed patients with CD, all of them had therapeutic changes made. One capsule retention occurred.

CONCLUSIONS

Capsule endoscopy may lead to reclassification of IBD from UC/ IC to definitive CD. In addition, previously diagnosed patients with CD may be found to have a more significant burden of small bowel disease. Taken together, this information may facilitate more targeted and effective therapies and potentially lead to better patient outcomes.

Wireless capsule endoscopy in the investigation of intestinal Behçet's syndrome

OBJECTIVE

Intestinal Behçet's Syndrome (BS) is a difficult diagnosis to establish. We describe the use of wireless capsule endoscopy (WCE) in the investigation of 11 patients with suspected intestinal BS.

METHODS

Out of 11 patients, 10 with suspected intestinal BS were found to have small intestinal ulcers on capsule endoscopy. Each case was retrospectively assessed for symptoms, signs, anaemia, other investigations, treatment and complications.

RESULTS

All 11 patients had established diagnoses of BS as defined by the International Study Group criteria. Central abdominal pain and change in bowel habit were the predominant symptoms, both occurring in seven patients. Upper gastrointestinal (GI) endoscopy and colonoscopy identified duodenitis, ileitis and colitis in three patients. Barium studies and CT were normal in all cases. WCE revealed small intestinal ulcers throughout the ileum in five patients and ulcers located either in the proximal and/or distal ileum in five other patients. One patient had significant symptoms, signs and ulcers leading to a change in treatment to infliximab, and this resulted in resolution of symptoms and ulcers. Ten age- and sex-matched controls investigated for unexplained GI symptoms had no intestinal lesions on capsule endoscopy.

CONCLUSION

WCE is useful in the investigation of GI symptoms in BS. It is particularly helpful in those patients in whom conventional investigations have been normal or fail to account for symptoms and signs. This technique may guide treatment and provide a better understanding of intestinal pathology in BS.

Effectiveness and safety of capsule endoscopy in the diagnosis of small bowel diseases

GOALS

To assess the effectiveness, safety, and clinical use of capsule endoscopy (CE) in the diagnosis of small bowel diseases.

STUDY

Systematic review carried out in the main electronic databases, including MEDLINE, EMBASE, and COCHRANE. Papers were selected independently by the 2 researchers and the quality was determined using a purpose-designed scale.

RESULTS

A total of 9 systematic reviews and 28 original papers were included [11 assessed obscure gastrointestinal bleeding, 9 Crohn's disease (CD), and 4 hereditary polyposis syndromes]. The diagnostic yield of CE for the diagnosis of obscure gastrointestinal bleeding ranged from 39% to 77%. The diagnostic yield of push enteroscopy was lower than 40% in all but 1 study. CE detected suggestive findings in 19% to 71% of patients with suspected CD, whereas radiologic techniques did so in only 0% to 37% of the cases. In patients with suspected recurrence, detection with these techniques was 58% to 81% and 19% to 67%, respectively. Endoscopic capsule detected a greater number of polyps in patients with polyposis syndromes but other techniques allowed for better localization.

CONCLUSIONS

Although CE occupies a preferential place in the diagnosis of gastrointestinal bleeding and CD; there is insufficient evidence to establish whether it could be used as a first line diagnostic test. The evidence is insufficient to ascertain this technique's usefulness in small bowel disorders other than obscure bleeding or CD.

Antiglycan antibodies as serological markers in the differential diagnosis of inflammatory bowel disease

BACKGROUND

The objective of the study was to evaluate the diagnostic accuracy of recently developed antiglycan serological tests in clinical practice for the diagnosis of Crohn's disease.

METHODS

This study was a cohort analysis of both clinical and biochemical parameters of patients with diagnosed inflammatory bowel disease compared with those in a control population. Antiglycan antibodies were determined using commercially available enzyme immunoassays. The setting was the outpatient unit of the gastroenterology department of a large, tertiary-care referral academic hospital. Participants were 214 consecutive patients, enrolled over a 5-month period, including 116 with Crohn's disease and 53 with ulcerative colitis, as well as 45 with other gastrointestinal diseases and 51 healthy controls.

RESULTS

Anti-Saccharomyces cerevisiae antibodies showed the best performance (54% sensitivity and 88%-95% specificity for Crohn's disease). Among patients with negative anti-Saccharomyces antibodies, 19 (34%) had high titers of at least another tested antiglycan antibody. Anti-Saccharomyces and anti-laminaribioside antibodies were associated with disease involving the small bowel and with penetrating or stricturing phenotype. Anti-laminaribioside was significantly higher in patients with a familial history of inflammatory bowel disease.

CONCLUSIONS

The new proposed serological markers are significantly associated with Crohn's disease, with low sensitivity but good specificity. About one third of anti-Saccharomyces-negative patients may be positive for at least 1 of those markers. Antiglycan antibodies appear to be associated with characteristic localization and phenotype of the disease.

Capsule endoscopy and imaging tests in the elective investigation of small bowel disease

Capsule endoscopy enables high-resolution depiction of small bowel mucosa and has been shown, by several studies, to have a high diagnostic yield in a variety of small bowel diseases. In this review, we critically assess the contributions of capsule endoscopy and imaging tests in common small bowel disorders. Radiological tests that only assess the small bowel mucosa will be less useful in the era of capsule endoscopy.

[Small bowel stromal tumors diagnosed by capsule endoscopy]

Small intestinal stromal tumors account for approximately 35% of all gastrointestinal stromal tumors. Gastrointestinal bleeding is considered as one of the main clinical symptoms for SISTs. Capsule endoscopy has brought revolution in small bowel diagnostics, as it is considered the best method of visualisation of the entire small intestine. Besides, it is well tolerated by patients and is accompanied by a low number of complications. It is also indicated as the first diagnostic method in gastrointestinal bleeding of obscure origin, following negative upper endoscopy and colonoscopy.

CASE REPORT

2 patients (a male and a female, aged 58 and 69, respectively) presented with obscure gastrointestinal bleeding have been examined by capsule endoscopy after negative upper endoscopy and colonoscopy. Videorecords have been assessed in both cases by two independent experts. The capsule reached the Bauchin-valve in both cases during the 8 hours of the testing time and the entire small bowel was clearly visible. - Based on the capsule endoscopic images, for one of the two cases a tumor has been reported as the background of the small intestinal bleeding. In the other case we could mark the location of the bleeding, while we were unable to ascertain the type of the actively bleeding lesion during the test. In order to determine the accurate bleeding source double-balloon enteroscopy was performed in the second case. After surgery the histological and immunohistochemical tests have justified the presence of spindle cell GISTs. Taking into consideration the Fletcher-classification, for the tumor size and the mitotic index, both cases can be classified as a GIST of low malignant potential.

CONCLUSIONS

An early diagnosis and application of a definitive therapy become possible by using capsule endoscopy, therefore the chance of survival of the patients might be increased.

Video capsule endoscopy of the small bowel

PURPOSE OF REVIEW

It is now more than 6 years since capsule endoscopy was first introduced to the gastroenterological community. This disposable 26 x 11 mm video capsule, containing its own optical dome, light source, batteries, transmitter and antenna, is swallowed with water after a 12 h fast. The capsule is propelled via peristalsis through the gastrointestinal tract, capturing about 60 000 digital images, and is excreted naturally. Capsule endoscopy has become a first-line tool for detecting abnormalities in the small bowel, because all other imaging technologies are rather ineffective. This review covers recent developments in capsule endoscopy technology and provides an update of its main indications.

RECENT FINDINGS

There are some clear indications for capsule endoscopy: obscure gastrointestinal bleeding, suspected small bowel tumour (in which it is becoming a primary investigational tool), suspected Crohn's disease, surveillance of inherited polyposis syndromes, drug-induced small bowel injury, and any abnormal small bowel imaging. Controversy persists regarding what is a normal small bowel appearance, which is exacerbated by the inability to take biopsies and thus differentiate between entities; with technological advances, however, it is hoped that this will be addressed.

SUMMARY

Capsule endoscopy has been incorporated into the gastroenterologists' daily life, changing the approach to many small bowel pathologies.

Technology Insight: new techniques for imaging the gut in patients with IBD

Advances in techniques for imaging the gut continue to drive the rapid development of modalities for diagnosing and assessing the activity of IBD. Abdominal ultrasound and magnetic resonance enterography have shown great potential for the diagnosis of IBD and assessment of its distribution, with the benefit of avoiding radiation exposure and serving as a safe option for pregnant patients. CT enterography or CT enteroclysis, with neutral or negative contrast, seems to be a sensitive and specific modality for detecting disease in the small bowel. The role of CT or magnetic resonance colonography in patients with IBD remains uncertain and these modalities are now best reserved for patients who decline or cannot undergo standard endoscopic evaluations. Capsule endoscopy might be the most sensitive modality for the detection of mucosal small bowel disease, but its specificity remains in question. Double-balloon endoscopy is an exciting new tool that has the distinct advantage of enabling biopsy or treatment of lesions detected during the procedure. All these techniques are at the forefront of the rapidly evolving field of imaging the gut in patients with IBD.

CT Enteroclysis

Computed tomographic (CT) enteroclysis is a hybrid technique that combines the methods of fluoroscopic intubation-infusion small-bowel examinations with that of abdominal CT. The use of multidetector CT technology has made this a versatile examination that has evolved into two distinct technical modifications. CT enteroclysis can be performed by using positive enteral contrast material without intravenous contrast material and neutral enteral contrast material with intravenous contrast material. CT enteroclysis has been shown to be superior to other imaging tests such as peroral small-bowel examinations, conventional CT, and barium enteroclysis, except in the demonstration of early apthous ulcers of Crohn disease. CT enteroclysis is complementary to capsule endoscopy in the elective investigation of small-bowel disease, with a specific role in the investigation of Crohn disease, small-bowel obstruction, and unexplained gastrointestinal bleeding.

Current and future diagnostic approaches: from serologies to imaging

Advances in serologic markers and imaging modalities continue to revolutionize diagnostic approaches to inflammatory bowel disease (IBD). Autoimmune and antimicrobial antibodies demonstrate diagnostic value in those patients with a moderate pretest probability of disease. Emerging data also support the use of antimicrobial antibody levels as a predictive tool for small bowel complications and the need for future surgery. In addition to being a prognostic marker in patients with acute severe colitis, serum C-reactive protein has been shown to correlate with clinical, endoscopic, and radiologic measures of disease activity. Capsule endoscopy and double-balloon endoscopy allow for visualization of the entire small bowel, and double-balloon endoscopy also has the capability to treat lesions. CT enterography is beginning to replace small bowel follow-through because of its high sensitivity and specificity for disease of the small intestine. Both CT and magnetic resonance enterography detect luminal and extraluminal abnormalities, with MRI serving as a safe imaging option in cases of pregnancy and renal insufficiency. These newer modalities add to the armamentarium clinicians can use for evaluation of IBD.

Wireless capsule endoscopy and small intestine contrast ultrasonography in recurrence of Crohn's disease

BACKGROUND

The best available tool to assess recurrence of Crohn's disease (CD) is ileocolonoscopy (CC). Small intestine contrast ultrasonography (SICUS) and wireless capsule endoscopy (WCE) are noninvasive techniques able to detect small bowel lesions. In a prospective longitudinal study, we aimed to investigate the usefulness of SICUS and WCE for assessing postoperative recurrence of CD 1 year after surgery, using CC as the gold standard.

METHODS

Twenty-two patients (11 men, median age 33 years, range 22-67 years) undergoing ileocolonic resection for CD were prospectively followed from July 2003 to May 2006, with the Crohn's Disease Activity Index (CDAI) used for clinical assessment every 3 months for 1 year. At 1 year, recurrence was assessed by SICUS and CC, followed by WCE. CD recurrence was assessed by CC (Rutgeerts score). SICUS was performed after ingestion of polyethylene glycol, and WCE was performed with Given M2A equipment.

RESULTS

At 1 year, all 22 patients had inactive CD (CDAI < 150). In 5 patients, WCE was not performed because of luminal narrowing or stenosis. Seventeen of the 22 patients had all 3 techniques performed. CC detected recurrence in 21 of 22 patients. Lesions compatible with recurrence were detected by SICUS in all 22 patients (1 false positive). When considering only the 17 patients studied by all 3 techniques, recurrence was detected by CC in 16 of 17 patients, whereas lesions compatible with recurrence were detected by SICUS in all 17 patients (16 true positives [TPs], 1 FP) and by WCE in 16 of 17 patients (16 TPs, 1 true negative).

CONCLUSIONS

The present findings suggest that SICUS and WCE may be used as noninvasive techniques for the assessment of recurrence of CD in patients being regularly followed up after ileocolonic resection.

Capsule enteroscopy and radiology of the small intestine

In a very few years, the video capsule for small bowel enteroscopy has gained widespread clinical acceptance. It is readily ingested, disposable, and allows for a complete, low-invasive endoscopic examination of the entire mucosa of the small bowel. It is a patient-friendly method and a first-line procedure in the difficult evaluation of obscure gastrointestinal bleeding. It has the highest proven figure of diagnostic sensitivity for detecting lesions of the mucosa, irrespective of aetiology. The limitations of capsule endoscopy include difficulty in localising mucosal lesions anatomically and its restricted use in patients with dysphagia, strictures or motor dysfunction. Strictures, transmural and extra-mural lesions in patients with small bowel Crohn's disease are evaluated by MRI- enterography and CT-enterography.

New frontiers in capsule endoscopy

Capsule endoscopy (CE) was launched at the beginning of this millennium and has since become a well-established tool for evaluating the entire small bowel for manifold pathologies. CE far exceeded our early expectations by providing us with a tool to establish the correct diagnosis for elusive gastrointestinal (GI) conditions such as obscure GI bleeding, Crohn's disease, polyposis syndrome, and others. Recent evidence has shown CE to be superior to other imaging modalities, such as small bowel follow-through X-ray, colonoscopy with ileoscopy, computerized tomographic enterography, magnetic resonance enteroclysis, and push enteroscopy, for diagnosing small bowel pathologies. Gastroenterologists would prefer the convenience of a single capsule that can create images of the area from the oral cavity to the anal canal in one 'shot'. Because of anatomic and physiologic differences in the GI tract, however, it may not be possible to use the same capsule and so we would need a different one for each organ. In addition to the pioneer small bowel capsule, there is now an esophageal capsule, and a colonoscopy capsule will soon be available. The ideal CE should be capable of performing a biopsy or carrying out an online analysis (an 'optical' biopsy) and 'stop' bleeding by an epinephrine injection, a heat probe, argon plasma coagulation, etc. The ultimate capsule would include special detectors for white blood cells, and it would check oncological markers (e.g. CEA, CA 19-9), perform serology tests (e.g. antiendomysial, IgE), and measure various cytokines, pH levels, temperature and pressure, as well as deliver drugs. The capsule's motility feature in the small bowel may open a window to study the pathophysiology of relatively elusive medical entities, such as irritable bowel syndrome. The optimal capsule needs to contain an automatic computerized system for automatic detection of pathologies, such as that present in the ECG-Holter recording, in order to overcome the drawback of time-consuming viewing. Our dream is that endoscopists will be able to 'control and steer' the CE, as they are able to do in standard endoscopy. This would mean being able to maintain the capsule steady in a selected area and hold the view in order to have more time to examine the opposite wall of the bowel. In conclusion, future gastroenterologists will have a number of CEs from which to choose, according to the purpose of the evaluation, whether it be diagnostic and/or therapeutic. Just as the idea of a swallowed capsule taking images as it travels along the human anatomy was once in the realm of sheer fantasy, we have every reason to believe that the ultimate CE will become a reality in the not far distant future.

Radiologic Investigations Complement and Add Diagnostic Information to Capsule Endoscopy of Small-Bowel Diseases

OBJECTIVE

The purpose of our study was to review how commonly performed radiologic examinations compare with capsule endoscopy in the investigation of small-bowel diseases, to analyze the limitations of capsule imaging, and to propose an algorithm for use of specific radiologic examinations to complement wireless capsule endoscopy.

CONCLUSION

The diagnostic yield of capsule endoscopy is superior to that of radiologic examinations except air double-contrast enteroclysis for mucosal details. Radiologic investigations find new applications in clinical practice by complementing capsule endoscopy to overcome its limitations.

Video capsule endoscopy in patients with known or suspected small bowel stricture previously tested with the dissolving patency capsule

GOALS

To assess the safety of the Pillcam in patients with known or suspected radiologic stricture, previously tested for small bowel patency using the Given Patency capsule.

BACKGROUND

Intestinal stricture contributes a major contraindication to video capsule endoscopy (VCE), because of the risk of capsule retention.

STUDY

Twenty-seven patients (16 female, mean age 44.2 y) with known or suspected intestinal stricture were enrolled prospectively. Twenty-four had Crohn's disease, 2 had adhesive syndrome and 1 had a suspected ischemic stricture. Patients underwent the Patency capsule test. In patients in whom the Patency capsule was excreted intact within 72 hours postingestion without occurrence of any adverse event, VCE was performed to assess the presence of strictures or other gastrointestinal pathologies. The following parameters were evaluated: transit time of Patency capsules and/or tags from ingestion to excretion, condition of the Patency capsule at excretion, transit time of the Pillcam capsule, the ability of Pillcam capsule to detect intestinal strictures and small bowel pathologies, any adverse events.

RESULTS

Twenty-five patients (92.6%) retrieved the Patency capsule in the stools. Six patients complained of abdominal pain, 4 of whom excreted a nonintact capsule. Hospitalization was required in 1 (4.3%) patient with Crohn's disease due to occlusive syndrome. Fifteen patients (65.3%) excreted an intact Patency capsule after a mean transit time of 25.6 hours without any adverse events. These 15 patients underwent the VCE successfully.

CONCLUSIONS

Passage of an intact Patency capsule across a small bowel stricture provides direct evidence of functional patency of the gut lumen and allows a safe VCE. Intestinal strictures should not be considered an absolute contraindication for VCE.

Imaging of the small bowel in Crohn's disease: A review of old and new techniques

The investigation of small bowel morphology is often mandatory in many patients with Crohn’s disease. Traditional radiological techniques (small bowel enteroclysis and small bowel follow-through) have long been the only suitable methods for this purpose. In recent years, several alternative imaging techniques have been proposed. To review the most recent advances in imaging studies of the small bowel, with particular reference to their possible application in Crohn’s disease, we conducted a complete review of the most important studies in which traditional and newer imaging methods were performed and compared in patients with Crohn’s disease. Several radiological and endoscopic techniques are now available for the study of the small bowel; each of them is characterized by a distinct profile of favourable and unfavourable features. In some cases, they may also be used as complementary rather than alternative techniques. In everyday practice, the choice of the technique to be used stands upon its availability and a careful evaluation of diagnostic accuracy, clinical usefulness, safety and cost. The recent development of innovative imaging techniques has opened a new and exciting area in the exploration of the small bowel in Crohn’s disease patients.

Cápsula endoscópica: fundamentos y utilidad clínica

Wireless capsule endoscopy (PillCam) represents a major advance in the study of small bowel disease since this procedure allows images of hitherto unreachable areas to be obtained. Approved for use by the Food and Drug Administration in August 2000, capsule endoscopy is currently a first line procedure in the study of small bowel disease. This technique consists of a non-reusable swallowable capsule (length 26 x 11 mm) that acquires video images while moving through the gastrointestinal tract propelled by natural peristalsis. The main indications of capsule endoscopy are evaluation of obscure gastrointestinal bleeding, chronic anemia, and inflammatory bowel disease. Contraindications are swallowing disorders and known or suspected small bowel strictures of any etiology. Consequently, small bowel follow through is useful prior to capsule endoscopy when these lesions are suspected.

Endoscopic placement of the small-bowel video capsule by using a capsule endoscope delivery device

BACKGROUND

Capsule endoscopy performed via the traditional peroral route is technically challenging in patients with dysphagia, gastroparesis, and/or abnormal upper-GI (UGI) anatomy.

OBJECTIVE

To describe the indications and outcomes of cases in which the AdvanCE capsule endoscope delivery device, which has recently been cleared by the Food and Drug Administration, was used.

DESIGN

Retrospective, descriptive, case series.

SETTING

Tertiary care, university hospital.

PATIENTS

We report a case series of 16 consecutive patients in whom the AdvanCE delivery device was used. The study period was May 2005 through July 2006.

INTERVENTIONS

Endoscopic delivery of the video capsule to the proximal small bowel by using the AdvanCE delivery device.

MAIN OUTCOME MEASUREMENTS

Indications, technique, and completeness of small bowel imaging in patients who underwent endoscopic video capsule delivery.

RESULTS

The AdvanCE delivery device was used in 16 patients ranging in age from 3 to 74 years. The primary indications for endoscopic delivery included inability to swallow the capsule (10), altered UGI anatomy (4), and gastroparesis (2). Of the 4 patients with altered UGI anatomy, 3 had dual intestinal loop anatomy (ie, Bilroth-II procedure, Whipple surgery, Roux-en-Y gastric bypass) and 1 had a failed Nissen fundoplication. In all cases, the capsule was easily deployed without complication, and complete small intestinal imaging was achieved.

LIMITATIONS

Small patient size.

CONCLUSIONS

Endoscopic placement of the Given PillCam by use of the AdvanCE delivery device was safe and easily performed in patients for whom capsule endoscopy would otherwise have been contraindicated or technically challenging.

Diagnostic and therapeutic impact of double-balloon enteroscopy (DBE) in a series of 100 patients with suspected small bowel diseases

BACKGROUND

Double-balloon enteroscopy is a newly developed endoscopic method allowing non-surgical full-length exploration of the small bowel, biopsies sample and endoscopic treatment of previously inaccessible lesions.

AIM

To prospectively assess the diagnostic and therapeutical impact of double-balloon enteroscopy in patients with suspected or documented small bowel disease.

PATIENTS AND METHODS

One hundred consecutive patients referring to our centre for suspected small bowel disease underwent double-balloon enteroscopy. Starting insertion route (anal or oral) of double-balloon enteroscopy was chosen according to the estimated location of the suspected lesions basing on the clinical presentation and on the findings, when available, of previous endoscopic or radiological investigations. Major indications for the procedures were acute recurrent or chronic mid-gastrointestinal bleeding (n=71), suspected gastrointestinal tumours (n=10), suspected Crohn's disease (n=6), chronic abdominal pain and/or chronic diarrhoea (n=8), refractory celiac disease (n=5).

RESULTS

One hundred and eighteen double-balloon enteroscopy procedures were carried out. Oral and anal route double-balloon enteroscopies were performed in 54 and 28 patients, respectively, while 18 patients underwent a combination of both approaches. Overall diagnostic yield of double-balloon enteroscopy resulted 69%. Most common pathological findings included angiodysplasias (n=39), ulcerations and erosions of various aetiologies (n=21), tumours (n=7) and ileal stenosis in patients with Crohn's disease suspicion (n=2). In the 65% of the patients examined, double-balloon enteroscopy findings influenced the subsequent clinical management (endoscopic, medical or surgical treatment). No major complications related to the procedure occurred.

CONCLUSIONS

Our prospective analysis shows that double-balloon enteroscopy is a useful, safe and well-tolerated new method with a high diagnostic and therapeutic impact for the management of suspected or documented small bowel diseases.

Small bowel capsule endoscopy: a systematic review

Wireless capsule endoscopy offers a revolutionary diagnostic tool for small bowel diseases. Since its formal introduction, it has become an integral part of the diagnostic evaluation for obscure gastrointestinal bleeding. This relatively noninvasive imaging modality offered by small bowel capsule endoscopy is appealing to both patients and providers and consequently, the desire to expand its diagnostic role continues to grow. The use of CE in the diagnosis of Crohn disease and chronic diarrhea is being further investigated, as is the potential of employing this technique as a cancer surveillance mechanism in patients with hereditary polyposis syndromes which may involve the small bowel. This review article discusses the current indications for small bowel capsule endoscopy, the results of capsule endoscopy in patients with obscure gastrointestinal bleeding and small bowel diseases, and patient outcomes following capsule endoscopy. Capsule endoscopy is compared with traditional diagnostic modalities, including small bowel series, enteroclysis, CT, and push enteroscopy. Small bowel capsule endoscopy is the procedure of choice to evaluate obscure gastrointestinal bleeding, and is superior to radiographic procedures in detecting Crohn disease of the small bowel.

Clinical outcome of patients examined by capsule endoscopy for suspected small bowel Crohn's disease

BACKGROUND

Capsule endoscopy has a greater diagnostic yield than radiology for detecting subtle inflammatory changes of the small bowel mucosa, but the clinical significance of these abnormalities is still uncertain because of the lack of long-term follow-ups.

AIM AND METHODS

To verify the accuracy of capsule endoscopy in a cohort of patients with suspected Crohn's disease of the small bowel, taking as 'gold standard' the final diagnosis made after a long follow-up. From April 2002 to March 2005, we enrolled and examined by capsule endoscopy 27 consecutive patients with abdominal pain and diarrhea lasting more than 3 months and at least one of the following: anaemia, weight loss, fever, extra-intestinal manifestation(s) of inflammatory bowel disease. All patients already had an unremarkable pan-endoscopy, serology for celiac disease and intestinal radiology inconclusive for small bowel abnormality. On the basis of capsule endoscopy findings, patients were distributed in three groups; Group A had severe stricturing lesions requiring surgery; Group B, moderate inflammatory lesions further investigated invasively; Group C, minimal inflammatory changes or normal findings, clinically observed every 3 months (median 21 months, range 15-29).

RESULTS

Small bowel inflammatory lesions were found in 16 of the 27 patients (diagnostic yield 59%). Three had surgery (Group A) and Crohn's disease was confirmed in two; the remainder had ileal adenocarcinoma in a pathological context of chronic inflammation. Crohn's disease was histologically confirmed in four of the five patients in Group B. Group C comprised 19 patients; Crohn's disease was confirmed in seven out of eight with positive capsule endoscopy, while only one of the patients with normal findings later developed overt ileal Crohn's disease. Sensitivity, specificity, positive and negative likelihood ratio were, respectively, 93%, 84%, 5.8 and 0.08. Assuming a 50% pre-test probability of disease, capsule endoscopy gave a post-test probability of 85%.

CONCLUSIONS

In our selected cohort, capsule endoscopy was highly sensitive in detecting small bowel inflammatory changes, enhancing by nearly 35% the pre-test probability of structural small bowel disease. Focal erythema and luminal debris may limit the specificity of capsule endoscopy.

Capsule endoscopy: an alternative to duodenal biopsy for the recognition of villous atrophy in coeliac disease?

BACKGROUND

Villous atrophy present on a duodenal biopsy remains the 'gold standard' diagnostic test for coeliac disease. However, endoscopic biopsy may cause morbidity and discomfort. Our aim was to evaluate wireless capsule endoscopy as an alternative test for the recognition of villous atrophy.

METHOD

Twenty-one patients with a positive endomysial antibody referred for endoscopy and duodenal biopsy were also offered a wireless capsule endoscopy to evaluate their small bowel. Concurrently, other patients (n=23) referred for a wireless capsule endoscopy acted as controls. Wireless capsule endoscopy reports were assessed for the presence of villous atrophy by one blinded investigator.

RESULTS

Twenty endomysial antibody positive patients subsequently had villous atrophy on duodenal biopsy. The controls all had normal duodenal biopsies (with a negative endomysial antibody) and no evidence of villous atrophy noted on their wireless capsule endoscopy. Of the 20 endomysial antibody positive patients with confirmed villous atrophy on biopsy, 17 had villous atrophy also detected by wireless capsule endoscopy. The sensitivity, specificity, positive and negative predictive values for wireless capsule endoscopy recognising villous atrophy were 85%, 100%, 100%, 88.9%, respectively.

CONCLUSION

Wireless capsule endoscopy may be an option to recognise villous atrophy in patients with a positive endomysial antibody who are unwilling, or unable to have a gastroscopy. However, a negative test should be followed by a biopsy if coeliac disease is to be excluded.

Evolving diagnostic strategies for inflammatory bowel disease

Advances in serologic markers, endoscopy, and radiology have led to rapid expansion of diagnosis and disease activity assessment of inflammatory bowel disease (IBD). Serologic markers may have diagnostic value in patients with an intermediate pretest probability of IBD, but these serology tests lack complete sensitivity, and a negative serology result does not exclude the possibility of IBD. Several recent studies have confirmed the utility of serologies in predicting intestinal complications and need for surgery in Crohn's disease. Serum C-reactive protein concentrations correlate with clinical, endoscopic, and radiologic measures of disease activity and appear to have prognostic value in acute severe colitis. Capsule and double balloon endoscopy allow visual inspection of previously inaccessible areas of the small intestine and are useful for patients with suspected small bowel involvement but negative results on conventional testing. CT enterography, which entails oral ingestion of a large volume of a neutral or negative contrast agent and scanning that highlights differences in contrast between the lumen and the bowel wall, appears to be more sensitive than small bowel follow-through for detecting small bowel Crohn's disease and provides extraluminal information. Magnetic resonance enterography uses principles similar to those for CT enterography, and early results are encouraging.

The use of wireless capsule endoscopy in clinical diagnostic gastroenterology

This profile describes a new wireless video endoscopy device designed to image previously inaccessible areas of the gastrointestinal tract with unprecedented precision and clarity. This PillCam technology involves a disposable, ingestible camera that transmits more than 50,000 digital images of the small bowel to personal computer software. The wireless capsule endoscopy technology supplements and is rapidly replacing standard small bowel imaging techniques, and its use has revolutionized conventional ideas about the small bowel's role in many conditions such as Crohn's disease and occult blood loss. In addition to the small bowel device, an esophageal adaptation was released in January 2005. This capsule technology anticipates exponential growth in both diagnostic and possible therapeutic dimensions in the future.

Capsule endoscopy in patients with chronic abdominal pain

BACKGROUND

Patients with chronic abdominal pain consult gastroenterologists frequently, requiring a large number of examinations.

AIM

To assess the diagnostic yield of capsule endoscopy in patients with chronic abdominal pain of unknown origin and negative diagnostic work-up.

PATIENTS

From January 2002 to September 2004, 16 patients (10 female; mean age 42.7 years) who complained of chronic abdominal pain were referred to our unit for capsule endoscopy.

METHODS

Chronic abdominal pain was defined as continuous or almost continuous, for at least 3 months and without criteria for other gastrointestinal disorders. All patients had a previous diagnostic work-up including abdominal ultrasonography, oesophagogastroduodenoscopy, colonoscopy and small bowel follow through, performed within 2 months.

RESULTS

Capsule endoscopy was normal in 12 patients (75%). Small bowel abnormalities were found in three patients, but were considered irrelevant. In one patient (6.3%), capsule endoscopy revealed ileal erosions and inflammation and was retained in a stricture undetected by radiology. This patient underwent elective surgery which revealed an ileal carcinoid neoplasm.

CONCLUSIONS

Capsule endoscopy identified a specific cause of chronic abdominal pain in only one patient. Capsule endoscopy is a safe procedure but does not seem to play an important role in the evaluation of patients with chronic abdominal pain of unknown origin.

Clinical features of patients with negative results from traditional diagnostic work-up and Crohn's disease findings from capsule endoscopy

INTRODUCTION

Capsule endoscopy (CE) can detect Crohn's disease in patients with suggestive symptoms but with negative results from the traditional diagnostic work-up (ileocolonoscopy and small bowel follow-through). The objective of this study was to determine which clinical features predict the diagnosis of Crohn's disease by CE in this subgroup of patients.

MATERIAL AND METHODS

Twenty-three patients (7 men, 16 women; mean age: 40+/-15 y) with negative results from conventional imaging techniques were prospectively included in the study because of suspicion of Crohn's disease (long-standing abdominal pain and/or diarrhea and at least one of the following symptoms: anemia, weight loss, long-standing fever, perianal disease, extraintestinal manifestations typical of inflammatory bowel disease, elevated inflammatory parameters, or family history of inflammatory bowel disease).

RESULTS

CE diagnosed Crohn's disease in 6 patients (26%). Crohn's disease diagnosis was more frequent in patients with a combination of anemia and elevated inflammatory parameters than in patients without this combination (57% vs. 12.5%; P=0.04). The only statistically significant association between an inflammatory parameter and Crohn's disease was an increased platelet count.

CONCLUSIONS

CE is a useful tool for the diagnosis of subtle small bowel Crohn's disease. The diagnostic yield of CE in patients with suspicion of Crohn's disease but negative results from the traditional diagnostic work-up is significantly higher in patients with anemia and increased platelet count than in patients without this combination of clinical features.

Management of patients with chronic abdominal pain in clinical practice

A practical approach to the management of chronic abdominal pain is needed, given the high prevalence and impact of this problem. This article describes an approach that has evolved based on clinical experience and review of the literature: identifying predominant bloaters and abdominal wall pain; exclusion of organic disease, including consideration of laparoscopy for diagnosis; consideration of chronic functional abdominal pain and the first and second line pharmacotherapies; and seeking specialist care in a pain clinic, psychiatry, or behavioural therapy.

How much helpful is the capsule endoscopy for the diagnosis of small bowel lesions?

AIM: To assess the practically usefulness and diagnostic yield of this new method in a group of patients with suspected small bowel lesions.

METHODS: Capsule endoscopic (CE) examination by using M2A capsule endoscope TM (Given Imaging, Yoqneam, Israel) was performed in thirty nine patients (26 males, 13 females) with suspected small intestinal lesions. The composing of the patients was as follows: obscure gastrointestinal bleeding in twenty three patients, known Crohn’s disease in 6 patients, in whom CE was used to evaluate the severity and extension of the diseases, chronic diarrhea in 8 patients, abdominal pain in one patient and malignancy in one patient with unknown origin.

RESULTS: In two patients CE failed. Different abnormalities were revealed in 26 patients overall. Detection rate of abnormalities was highest among patients with obscure gastrointestinal bleeding and the source of bleeding was demonstrated in 17 of 23 patients with obscure bleeding (73.9%). Entero-Behcet was diagnosed in two patients by CE as a source of obscure gastrointestinal bleeding. In 6 patients with known Crohn's disease, CE revealed better evaluation of the disease extension. In 3 of 8 (37.5%) patients with chronic diarrhea; CE revealed some mucosal abnormalities as the cause of chronic diarrhea. In a patient with unexplained abdominal pain and in a cancer patient with unknown origin, CE examination was normal.

CONCLUSION: In our relatively small series, we found that capsule endoscopy is a useful diagnostic tool particularly in diagnosis of obscure gastrointestinal bleeding, chronic diarrhea and in estimating the extension of Crohn’s disease.

A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohn's disease

OBJECTIVES

Capsule endoscopy (CE) allows for direct evaluation of the small bowel mucosa in patients with Crohn's disease (CD). A number of studies have revealed significantly improved yield for CE over other modalities for the diagnosis of CD, but as sample sizes have been small, the true degree of benefit is uncertain. Additionally, it is not clear whether patients with a suspected initial presentation of CD and those with suspected recurrent disease are equally likely to benefit from CE. The aim of this study was to evaluate the yield of CE compared with other modalities in symptomatic patients with suspected or established CD using meta-analysis.

METHODS

We performed a recursive literature search of prospective studies comparing the yield of CE to other modalities in patients with suspected or established CD. Data on yield among various modalities were extracted, pooled, and analyzed. Incremental yield (IY) (yield of CE--yield of comparative modality) and 95% confidence intervals (95% CI) of CE over comparative modalities were calculated. Subanalyses of patients with a suspected initial presentation of CD and those with suspected recurrent disease were also performed.

RESULTS

Nine studies (n = 250) compared the yield of CE with small bowel barium radiography for the diagnosis of CD. The yield for CE versus barium radiography for all patients was 63% and 23%, respectively (IY = 40%, p < 0.001, 95% CI = 28-51%). Four trials compared the yield of CE to colonoscopy with ileoscopy (n = 114). The yield for CE versus ileoscopy for all patients was 61% and 46%, respectively (IY = 15%, p= 0.02, 95% CI = 2-27%). Three studies compared the yield of CE to computed tomography (CT) enterography/CT enteroclysis (n = 93). The yield for CE versus CT for all patients was 69% and 30%, respectively (IY = 38%, p= 0.001, 95% CI = 15-60%). Two trials compared CE to push enteroscopy (IY = 38%, p < 0.001, 95% CI = 26-50%) and one trial compared CE to small bowel magnetic resonance imaging (MRI) (IY = 22%, p= 0.16, 95% CI =-9% to 53%). Subanalysis of patients with a suspected initial presentation of CD showed no statistically significant difference between the yield of CE and barium radiography (p= 0.09), colonoscopy with ileoscopy (p= 0.48), CT enterography (p= 0.07), or push enteroscopy (p= 0.51). Subanalysis of patients with established CD with suspected small bowel recurrence revealed a statistically significant difference in yield in favor of CE compared with all other modalities (barium radiography (p < 0.001), colonoscopy with ileoscopy (p= 0.002), CT enterography (p < 0.001), and push enteroscopy (p < 0.001)).

CONCLUSIONS

In study populations, CE is superior to all other modalities for diagnosing non-stricturing small bowel CD, with a number needed to test (NNT) of 3 to yield one additional diagnosis of CD over small bowel barium radiography and NNT = 7 over colonoscopy with ileoscopy. These results are due to a highly significant IY with CE over all other modalities in patients with established non-stricturing CD being evaluated for a small bowel recurrence. While there was no significant difference seen between CE and alternate modalities for diagnosing small bowel CD in patients with a suspected initial presentation of CD, the trend toward significance for a number of modalities suggests the possibility of a type II error. Larger studies are needed to better establish the role of CE for diagnosing small bowel CD in patients with a suspected initial presentation of CD.

Results of videocapsule endoscopy in 250 patients with suspected small bowel pathology

We aimed to assess technical feasibility, clinical applicability, and diagnostic yield of videocapsule endoscopy (VCE) in a large group of unselected patients. VCE was performed with the Given Imaging swallowable capsule. Findings were considered diagnostic if the observed finding could explain the symptomatology of the patient. Findings were considered suspicious if an observed finding failed to completely explain the patient's symptoms. We studied 250 patients. A definite diagnosis was made in 95 patients (38%). Suspicious findings were noted in 80 patients (32%). No diagnosis was obtained in 74 patients (30%). The yield of VCE was higher in patients with suspected Crohn's disease. Mean viewing time decreased significantly from 51 +/- 14 to 30 +/- 7 minutes after reviewing 50 procedures. VCE is an important diagnostic tool, but a definite diagnosis is established in only 38% of the patients. The highest diagnostic yield is obtained in patients with suspected Crohn's disease.

Capsule endoscopy findings in patients with suspected Crohn's disease and biochemical markers of inflammation

BACKGROUND

Because it provides a direct view of superficial lesions in the small bowel, capsule endoscopy is a promising diagnostic tool for studying patients with suspected Crohn's disease undetected by conventional modalities.

AIM

To assess the role of capsule endoscopy in the diagnosis of patients with suspected Crohn's disease.

PATIENTS AND METHODS

Thirty-eight patients (16 males, mean age 46.2 years) with suspected Crohn's disease but negative at conventional imaging were examined using capsule endoscopy. They were divided into 2 groups: 12 patients with ongoing symptoms (Group 1), and 26 with ongoing symptoms and biochemical markers of inflammation (Group 2). Capsule endoscopy findings were classified as diagnostic (multiple erosions/ulcerations), suspicious (<or=3 erosions/ulcerations), non-specific and normal.

RESULTS

Capsule endoscopy findings were diagnostic for Crohn's disease in 13 (34.2%) patients, suspicious in 2 (5.3%), non-specific in 4 (10.5%) and normal in 19 (50%), with an overall detection rate of 39.5%. The yield of positive findings was 8.3% in Group 1 and 46.2% in Group 2 (p=0.022). Capsule endoscopy findings prompted specific measures or patient management changes in 39.5% of patients.

CONCLUSIONS

Capsule endoscopy has a high diagnostic yield in patients with suspected Crohn's disease and both clinical and biochemical markers of inflammation.

Capsule endoscopy: a meta-analysis for use with obscure gastrointestinal bleeding and Crohn's disease

In this study, CE was superior to push enteroscopy and small bowel radiography for diagnosing small bowel pathology in patients who had OGIB, and its yield may be comparable to intraoperative endoscopy. Incremental yield of CE over push enteroscopy and barium radiography is greater than 30% for clinically significant findings, primarily because visualization of additional vascular and inflammatory lesions is possible by CE.CE was also found to be superior to small bowel barium radiography, colonoscopy with ileoscopy, CT enterography, and push enteroscopy for diagnosing nonstricturing small bowel CD. These findings primarily result from a marked improvement in yield with the use of CE over all other methods in patients who had established CD and were evaluated for a small bowel recurrence. Because this analysis was designed to evaluate trials that examined the yield of various methods for the diagnosis of OGIB and CD, it is unknown whether these results will translate into improved patient outcomes with the use of CE versus alternate methods. Randomized controlled trials will be necessary to clarify this issue.