Biopsy of the small intestine with the Crosby-Kugler capsule. Experience in 3,866 peroral biopsies in children and adults

Capsule robots for the monitoring, diagnosis, and treatment of intestinal diseases

Current evidence suggests that the intestine as the new frontier for human health directly impacts both our physical and mental health. Therefore, it is highly desirable to develop the intelligent tool for the enhanced diagnosis and treatment of intestinal diseases. During the past 20 years, capsule robots have opened new avenues for research and clinical applications, potentially revolutionizing human health monitor, disease diagnosis and treatment. In this review, we summarize the research progress of edible multifunctional capsule robots in intestinal diseases. To begin, we introduce the correlation between the intestinal microbiome, intestinal gas and human diseases. After that, we focus on the technical structure of edible multifunctional robots. Subsequently, the biomedical applications in the monitoring, diagnosis and treatment of intestinal diseases are discussed in detail. Last but not least, the main challenges of multifunctional capsule robots during the development process are summarized, followed by a vision for future development opportunities.

Elemental Diet as a Therapeutic Modality: A Comprehensive Review

Elemental diets have been employed for the management of various diseases for over 50 years, with several mechanisms mediating their beneficial effects. Yet, they are underutilized due to poor palatability, access, cost, and lack of awareness regarding their clinical efficacy. Therefore, in this review, we aimed to systematically search and review the literature to summarize the formulation variability, mechanisms of action, clinical applications, and tolerability of the elemental diets in gastrointestinal diseases. While large prospective trials are lacking, elemental diets appear to exhibit objective and subjective clinical benefit in several diseases, including eosinophilic esophagitis, eosinophilic gastroenteritis, inflammatory bowel diseases, small intestinal bacterial overgrowth, intestinal methanogen overgrowth, chemoradiotherapy-associated mucositis, and celiac disease. Although some data support the long-term use of elemental diets as an add-on supplement for chronic pancreatitis and Crohn's disease, most of the literature on exclusive elemental diets focuses on inducing remission. Therefore, subsequent treatment strategies for maintaining remission need to be adopted in chronic/relapsing diseases. Several mechanistic pathways were identified to mediate the effects of elemental diets, including food additive and allergen-free content, high passive absorption rate, and anti-inflammatory properties. High rates of intolerance up to 40% are seen in the trials where exclusive elemental diets were administered orally due to poor organoleptic acceptability; however, when tolerated, adverse events were rare. Other limitations of elemental diets are cost, access, and lifestyle/social restrictions. Moreover, judicious use is advised in presence of a concomitant restrictive food intake disorders. Elemental diets offer a potentially highly efficacious dietary intervention with minor side effects. Palatability, cost, access, and social restrictions are common barriers of use. Prospective clinical trials are needed to elucidate the role of elemental formulas in the management of individual diseases.

Smart pills for gastrointestinal diagnostics and therapy

Ingestible smart pills have the potential to be a powerful clinical tool in the diagnosis and treatment of gastrointestinal disease. Though examples of this technology, such as capsule endoscopy, have been successfully translated from the lab into clinically used products, there are still numerous challenges that need to be overcome. This review gives an overview of the research being done in the area of ingestible smart pills and reports on the technical challenges in this field.

Small bowel biopsy by remote control: experimental study on dogs

Telemetry has been used for 30 years in medicine because it requires no link between patients and apparatus. To take advantage of this, we have developed a multipurpose intestinal capsule for the small bowel, with interchangeable tips triggered by remote control. A new tip, performing small bowel mucosal biopsy by remote control is presented. The location of the capsule is radiotransmitted by means of a cogwheel, which is rotated by contact with the intestinal wall. At the chosen site (ie, a number of centimeters from the pylorus), the remote control is activated and the mucosal biopsy is performed through a suction port and kept inside the tip. The capsule then passes throughout the bowel and is recovered in the stool to allow examination of the biopsies. The results of 24 studies on a dog (crossing of the pylorus, length, transit time, velocity) are analyzed to validate the method. Biopsies were accomplished in the stomach, the small bowel (ileum), and the colon. The device failed two times, but no complications occurred. Biopsies, with average surfaces were 6mm2, never penetrated the longitudinal muscular layer. The system is precise to within 3 cm, efficient, reliable, noninvasive, and causes minimal discomfort during investigation.

Diagnosis of hypolactasia and lactose malabsorption

The article briefly describes the various methods that are available for diagnosing hypolactasia. Special attention is drawn to the fact that different methods are useful at different levels of the health care organization. When the test result indicates lactose malabsorption, general malabsorption should be excluded by a glucose-galactose tolerance test, for example. If the glucose-galactose tolerance test produces a normal result, it can be assumed that the patient has primary adult-type selective lactose malabsorption. The possibility of secondary lactose malabsorption must be excluded according to the principles described by Villako & Maaroos (104).

Peroral endoscopic duodenal biopsy in infants and children

Peroral endoscopic duodenal biopsy was used in the diagnosis and follow-up of forty-nine infants and children with suspected small intestine disease. Their ages ranged between one month and 12 years. Fifty-four upper gastrointestinal endoscopy procedures were performed and 139 biopsies were taken. The mean procedure time was 3.2 min with a range of 1.5-5.5 min. There were no complications. Tissue adequate for histopathologic examination was obtained in all but one of the fifty-four procedures. On the basis of this experience we think that peroral endoscopic duodenal biopsy is faster, safer and as diagnostic as conventional suction biopsy in infants and children. It is also more informative when other diseases of the upper gastrointestinal tract are suspected.

Gluten-sensitive enteropathy: sequence of villous regrowth as viewed by scanning electron microscopy

Small-intestinal biopsy specimens from five children with gluten-sensitive enteropathy (GSE) were studied by scanning electron microscopy (SEM) before dietary treatment and sequentially after removal of gluten from the the diet. Compared with biopsy specimens from patients without evidence of villous atrophy, these specimens showed marked architectural changes. In patients with total villous atrophy observed by light microscopy, absent villi and prominent crypts were observed by SEM. Patients with subtotal villous atrophy had the first stages of villous formation characterized by semicircular ridge formation. Biopsy specimens obtained from the five patients with GSE after dietary treatment demonstrated a sequence of changes characterizing villous repair. The earliest change consisted of semicircular elevations of cells around the crypts. Unequal cellular repletion around the crypts and migration of the cells led to the formation of parallel ridges. Increased cell proliferation resulted in thickening and twisting of the ridges to form convoluted ridges. Increased complexity of the ridges appears to lead to the formation of cerebriform ridges, and septation at various points in the ridges results in the formation of mitten-like villi. In biopsy specimens from patients with villous atrophy from other causes, similar reparative changes were seen by SEM. Scanning electron microscopy is a useful adjunct to the light microscopic and dissecting microscopic assessment of small intestine biopsy specimens, and may be more sensitive tan light microscopy in documenting early morphologic response to dietary treatment for gluten-sensitive enteropathy.

Exposure to X-rays during small bowel biopsies in children

Peroral small bowel biopsy is a decisive step in the diagnosis of coeliac disease and is performed frequently. The patient's exposure to ionizing radiation during fluoroscopic control therefore deserves consideration. Compared to data in the literature, the biopsy method employed at the University Children's Hospital in Vienna achieves a markedly shorter duration of fluoroscopy. These values were registered during 1039 biopsies. In 439 examinations the exposure area products were also documented In 10 consecutive biopsies additional measurements were carried out by lithium fluoride thermoluminescence dosimeters attached to the patient. Expert biopsy-technique with precise and thoughtful use of modern fluoroscopes on the one hand, and critical self-control by routine documentation of the exposure area product and duration of fluoroscopy on the other can markedly reduce the patient's exposure to X-rays.

Peroral small-bowel biopsies in infants and children using a directable biopsy instrument

Fifty children, ages 1 month to 12 years, underwent peroral jejunal biopsy with a four-way directional suction biopsy instrument (Medi-Tech). Mucosal specimens were obtained in 88% of attempted biopsies in an average time of 4 min. Fluoroscopy time was minimal, and there were no complications.

Peroral small-intestinal biopsy: experience with the hydraulic multiple biopsy instrument in routine clinical practice

Experience of the peroral, hydraulic, multiple, small-bowel biopsy instrument is recorded and compared with reported experience of other peroral biopsy instruments. It is concluded that, in routine clinical practice, there is no particular danger associated with this instrument despite warnings to the contrary. Furthermore, biopsies are obtained at least as quickly as with other instruments and with great reliability. Since this instrument also enables multiple, precisely located biopsies to be taken from various levels of the small intestine, it could be considered the instrument of choice for peroral jejunal biopsy.

Protracted diarrhea and malnutrition in infancy: Changes in intestinal morphology and disaccharidase activities during treatment with total intravenous nutrition or oral elemental diets

Two therapeutic regimens were compared in 16 infants with protracted diarrhea and malnutrition. Eight patients were treated with total parenteral nutrition given via a central vein (group A); the remaining eight patients received a combination of dilute parenteral nutrients given in a peripheral vein plus continuous enteral feedings of an elemental diet (group B). All patients recovered although two infants in group B were switched to TPN treatment after a poor response to the elemental diet. Intestinal biopsies were performed: (1) before treatment; (2) after 2 to 3 weeks of TPN or elemental diet; and (3) after 2 to 3 weeks of Nutramigen feedings. Before treatment, all patients had atrophic changes in the jejunal epithelium and deficient disaccharidase and trypsin activities. The second biopsy showed morphologic recovery in all patients, incomplete recovery of lactase and trypsin in both treatment groups, and complete recovery of sucrase and maltase activities only in group B patients. The third biopsy showed normal morphology and complete recovery of all enzymes measured. The mean number of hospital days was 46 +/- 4.8 for group A and 34 +/- 1.6 for group B (p less than 0.05) suggesting that patients given enteral feedings early tended to have a more rapid return of intestinal function and of some intestinal enzymes.