Acute symptomatic small bowel obstruction due to capsule impaction

Feasibility and complications of videocapsule endoscopy in dogs weighing 7 kg or less

BACKGROUND

Videocapsule endoscopy (VCE) is a valuable tool for investigating gastrointestinal (GI) diseases in dogs. Its use is not recommended in dogs ≤4.3 kg, because of risks of GI endoscopic capsule (EC) retention and bowel obstruction.

OBJECTIVES

Describe the feasibility and complications of VCE in dogs ≤7 kg.

ANIMALS

Twenty-six client-owned dogs.

METHODS

Retrospective study describing the signalment, previous GI imaging, indications, findings, and complications of canine VCE studies submitted to Infiniti Medical between March 2020 and January 2023.

RESULTS

The median weight and age of dogs was 5.6 kg (range, 3-7) and 8.8 years (range, 1-16), respectively. Two capsules were administered endoscopically into the duodenum (1) and stomach (1). Sixteen out of 26 (62%, 95% CI, 40.51-79.70) dogs that underwent VCE had incomplete studies. Of the 24 capsules administered per os, 15 led to incomplete studies (battery died in the stomach (14), EC was vomited (1)). Body weight <5 kg significantly increased the risk of an incomplete study (OR: 3.67, 95% CI, 1.56-inf, P = .0074). Median esophageal, gastric, and small bowel transit time were 5 seconds (range, 1-180), 240 minutes (range, 17-335), and 73.5 minutes (range, 5-168), respectively. All 10 dogs with overt GI bleeding had a possible origin identified with VCE. Complications were limited to vomiting (1/26, 3.85%, 95% CI, 0-11.20).

CONCLUSIONS AND CLINICAL IMPORTANCE

Videocapsule endoscopy is a safe and informative procedure even when performed in dogs as small as 3 kg. However, weighing <5 kg increases the risk of incomplete studies.

Small bowel obstruction: what a gastroenterologist needs to know

PURPOSE OF REVIEW

Intrabdominal adhesions and intestinal hernias are the commonest cause of small bowel obstruction. Small bowel diseases, which cause small bowel obstruction, are rarer and often poses a challenge to gastroenterologists to diagnose and treat. In this review, small bowel diseases, which predispose to small bowel obstruction, are focused on, and their challenges in diagnosis and treatment.

RECENT FINDINGS

Diagnosis of causes of partial small bowel obstruction is improved with computed tomography (CT) and magnetic resonance (MR) enterography. In fibrostenotic Crohn's strictures and NSAID diaphragm disease, endoscopic balloon dilatation can delay the need for surgery if the lesion is short and accessible; however, many may still inevitably require surgery. Biologic therapy may reduce the need for surgery in symptomatic small bowel Crohn's disease wherein the strictures are predominantly inflammatory. In chronic radiation enteropathy, only refractory small bowel obstruction and those with nutritional difficulties warrant surgery.

SUMMARY

Small bowel diseases causing bowel obstruction are often challenging to diagnose and require numerous investigations over a period of time, which often culminate with surgery. Use of biologics and endoscopic balloon dilatation can help to delay and prevent surgery in some instances.

Undiagnosed Endoscopy Capsule Retention Causing Delayed Intestinal Obstruction in a Patient with a Small Bowel Neuroendocrine Tumor

BACKGROUND Capsule endoscopy has played a significant role in small bowel investigation, providing the opportunity of detecting neoplastic lesions to a greater degree and at an earlier stage than other diagnostic procedures. Failure to excrete the capsule with the feces within 48 h can lead to capsule retention with increased risk of further complications such as bowel obstruction and perforation. Capsule retention can remain undetected in case of incomplete follow-up and poor patient compliance. Acute small bowel obstruction as late as many months following capsule endoscopy investigation is very rare, with only a few cases reported in the published literature. We herein report a rare case of prolonged capsule retention which remained undiagnosed, resulting in small bowel obstruction 6 months after the initial investigation. CASE REPORT An 82-year-old woman presented with abdominal pain and symptoms suggestive of intestinal obstruction. The patient history included a capsule endoscopy investigation because of episodes of abdominal pain 6 months prior to admission. Both the outcome of the investigation and the excretion of the capsule remained undetermined due to her history of dementia and follow-up failure. Radiologic investigations identified the capsule causing small bowel obstruction. Upon surgery, the capsule was found to be impacted in a stenotic small bowel lesion, and a segmental small bowel resection was performed. Histologic examination revealed the presence of a stenotic small bowel neuroendocrine tumor. CONCLUSIONS Appropriate follow-up is necessary to diagnose the complication of capsule retention which, if it remains unrecognized, can cause life-threatening complications as late as many months after capsule endoscopy.

Capsule endoscopy - Recent developments and future directions

INTRODUCTION

Capsule endoscopy (CE) is an established modality in the diagnostic algorithm of small bowel (SB) pathology. Its use has expanded for investigation of upper and lower gastrointestinal diseases with similar prototypes.

AREAS COVERED

This review covers the role and recent advances of CE, as a non-invasive investigative tool.

EXPERT OPINION

The use of upper gastrointestinal CE is useful in patients who require surveillance for varices particularly in the current era of the COVID-19 pandemic. It has also shown high accuracy in the detection of upper gastrointestinal hemorrhage in patients presenting with a suspicion of hemorrhage. Findings on CE help to guide further management by device-assisted enteroscopy. The data on colon CE suggest comparable diagnostic accuracy to colonoscopy for polyp detection; however, more evidence is required in the high-risk group. Crohn's CE has become an integral part of the management of patients with Crohn's disease offering a comparative assessment tool post escalation of therapy. Artificial intelligence within CE has demonstrated similar if not better diagnostic yield compared to the human with a significantly shorter reading time. Artificial intelligence is likely to be in-built within CE reading platforms over the next few years minimizing reporting time and human error.

Predictors for Small Bowel Stenosis in Balloon-Assisted Enteroscopy

BACKGROUND

Predictors besides symptoms of obstruction indicating small bowel stenosis are little known.

AIMS

To detect predictors of small bowel stenosis in balloon-assisted enteroscopy.

METHODS

Over a 6-year period, 461 patients had enteroscopy for suspected small intestinal disease. Details of clinical manifestations, medical history, demographic characteristics, findings of examinations, information on enteroscopy, and treatment were retrospectively collected based on medical records. Small bowel stenosis was defined as stricture that over-tube cannot go through in enteroscopy. Univariate and multivariate analyses were performed to identify predictors for small bowel stenosis.

RESULTS

A total of 314 patients had definite diagnosis after enteroscopy, imaging modalities, and/or even surgical exploration. They were included in this study for analyses. Mean age for them was 48.2 years old (range 15-81 years). Small bowel stenosis was present in 59 patients (18.8%). Analyses showed that CT/MRI indicating stenosis was significantly associated with severe stenosis (p = 0.014) but insignificant related to general stenosis (p = 0.097). Predictive factors that accompanied stenosis were age ≥ 60 years (OR = 2.1, 95% CI 1.1-4.0), underweight (BMI ≤ 18.5) (OR = 3.4, 95% CI 1.4-8.4), symptoms of obstruction (OR = 3.6, 95% CI 1.8-7.4), and overt small bowel bleeding (OR = 0.5, 95% CI 0.2-0.9).

CONCLUSIONS

Small bowel stenosis more tended to occur to patients with symptoms of obstruction, no overt small bowel bleeding, age ≥ 60 years, or underweight.

The role of small bowel endoscopy for Crohn's disease

PURPOSE OF REVIEW

The review discusses the roles of small bowel capsule endoscopy and deep enteroscopy in patients with Crohn's disease. It highlights recent advances in the field and identifies areas where evidence is lacking.

RECENT FINDINGS

Small bowel capsule endoscopy has an important role in the follow-up of patients with Crohn's disease after escalation of therapy and in the postoperative assessment period following surgical resection. Device-assisted enteroscopy offers the therapeutic advantage of small bowel dilatation, which may result in a reduction in the number of surgical resections required, thus avoiding long-term complications, such as short bowel syndrome and malabsorption.

SUMMARY

Capsule endoscopy has an established role in the diagnosis and management of small bowel Crohn's disease. It is used in the setting of suspected Crohn's disease when ileocolonoscopy is negative and for the assessment of extent of small bowel disease in established Crohn's disease. It is relatively well tolerated because of the provision of patency capsule endoscopy to minimize the risk of inadvertent capsule retention. Device-assisted enteroscopy aids with the diagnosis of Crohn's disease as it enables histology to be taken from inflamed areas within the small bowel. Therapeutic procedures can be carried out during device-assisted enteroscopy including dilatation of Crohn's disease-related strictures and retrieval of retained capsules.

Capsule retention related to small bowel capsule endoscopy: a large European single-center 10-year clinical experience

BACKGROUND

The most concerning complication of video capsule endoscopy (VCE) is capsule retention (CR) in the gastrointestinal (GI) tract although clinical outcome and management of patients with CR are still uncertain in a large single center material.

OBJECTIVES

The aim of this retrospective study was to investigate incidence, causes, risk factors, management and clinical outcomes of CR in a large single center between 2001 and 2011.

RESULTS

2401 consecutive small-bowel (SB) VCEs were performed. CR was detected in 25 cases (1%). CR in patients with suspected and known Crohn's disease (CD) undergoing VCE occurred in 14/1370 (1%) including known CD 9/390 (2.3%) and suspected CD 5/980 (0.5%). CR in patients with obscure GI bleeding was observed in 11/816 (1.3%) cases. The SB was the most common site of CR with 17 cases followed by the esophagus (4 cases), colon (2 cases), and stomach (2 cases). Emergency endoscopic intervention (3 cases) and surgery (2 cases) was needed in 5 cases of CR. Elective capsule removal was performed by surgery in 6 cases and endoscopically in 8 cases. Three retained capsules dislodged after steroid treatment and another 3 cases of CR resolved without any intervention.

CONCLUSION

This large clinical material demonstrates that CR is a rare complication with a favorable clinical outcome. Most patients with CR can be electively managed with non-surgical intervention.

Clinical Practice Guideline for Enteroscopy

Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.

Colonic obstruction caused by video capsule entrapment in a metal stent

Video capsule endoscopy (VCE) has become the method of choice for visualizing the small bowel mucosa and is generally considered to be a safe method. Although uncommon, the most feared complication of VCE is capsule retention that can potentially lead to life-threatening bowel obstruction. Herein, we present for the first time a case of capsule retention in a colonic stent. The patient had known Crohn's disease with colonic involvement and underwent an uneventful but incomplete small bowel VCE for assessment of disease activity and extension for optimizing medical treatment. Five months later, the patient presented with intestinal obstruction due to a Crohn's-stricture in the sigmoid colon, which was successfully decompressed with a self-expandable metal stent. Nonetheless, two days later the patient showed signs of bowel obstruction again and abdominal X-ray showed that the capsule was trapped in the metal stent in the sigmoid colon. Subsequently, emergency surgery was performed and the patient fully recovered. Intestinal capsule retention necessitating interventional removal is rare. This report describes a unique case of capsule retention in a colonic metal stent and highlights the potential risk of performing capsule endoscopy examinations in patients with gastrointestinal stents.

Contraindications for video capsule endoscopy

Video capsule endoscopy (VCE) has been applied in the last 15 years in an increasing field of applications. Although many contraindications have been put into perspective, some precautions still have to be considered. Known stenosis of the gastrointestinal tract is a clear contraindication for VCE unless surgery is already scheduled or at least has been considered as an optional treatment modality. In patients with a higher incidence of stenosis, as in an established diagnosis of Crohn’s disease, clinical signs of obstruction, prior radiation or surgical small bowel resection, a preceding test with the self-dissolving patency capsule can override this contraindication. Endoscopic placement of the capsule should be considered in patients with swallowing disorders to avoid aspiration. Esophageal or gastric motility disorders may require endoscopic capsule transport or application of prokinetics if the real-time viewer proofs delayed transit. In pregnant women, VCE should be restricted to urgent cases where diagnosis cannot be postponed after delivery, as data on safety are missing. There is theoretical and clinical evidence that patients with implanted cardiac devices such as a pacemaker, cardioverters or left heart assist devices, can safely undergo VCE in spite of still existing contraindication by manufacturers. Children from the age of 2 years have safely undergone VCE. Although video capsules are not proven safe with magnetic resonance imaging (MRI), first single cases of patients incidentally undergoing MRI with an incorporated capsule have been reported, showing susceptibility artifacts but no signs of clinical harm.

SmartPill® as an objective parameter for determination of severity and duration of postoperative ileus: study protocol of a prospective, two-arm, open-label trial (the PIDuSA study)

INTRODUCTION

Postoperative ileus (POI) is a frequent complication after abdominal surgery (AS). Until today, neither a prophylaxis nor an evidence-based therapy exists. This originates from the absence of objective parameters evaluating the severity and duration of POI resulting in clinical trials of modest quality. The SmartPill(®), a capsule which frequently measures pH value, temperature and intraluminal pressure after swallowing, offers an elegant option for analysing gastrointestinal (GI) transit times and smooth muscle activity in vivo. As the use in patients in the first months after AS is not covered by the marketing authorisation, we aim to investigate the safety and feasibility of the SmartPill(®) immediately after surgery. Additionally, we analyse the influence of prokinetics and laxatives as well as standardised physiotherapy on postoperative bowel contractility, as scientific evidence of its effects is still lacking.

METHODS AND ANALYSIS

The PIDuSA study is a prospective, single-centre, two-arm, open-label trial. The SmartPill(®) will be applied to 55 patients undergoing AS having a high risk for POI and 10 patients undergoing extra-abdominal surgery rarely developing POI. The primary objective is the safety of the SmartPill(®) in patients after surgery on the basis of adverse device effects/serious adverse device effects (ADE/SADE). The sample size suggests that events with a probability of 3% could be seen with a certainty of 80% for at least once in the sample. Secondary objective is the analysis of postoperative intestinal activity in the GI tract in both groups. Furthermore, clinical signs of bowel motility disorders will be correlated to the data measured by the SmartPill(®) to evaluate its significance as an objective parameter for assessing POI severity. Additionally, effects of prokinetics, laxatives and physiotherapy on postoperative peristaltic activity recorded by the SmartPill(®) will be analysed.

ETHICS AND DISSEMINATION

The protocol was approved by the federal authority (94.1.05-5660-8976) and the local ethics committee (092/14-MPG). Findings will be disseminated through publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT02329912; Pre-results.

Prediction of patency capsule retention in known Crohn's disease patients by using magnetic resonance imaging

BACKGROUND AND AIMS

Evaluation of small-bowel patency is recommended before swallowing video capsule endoscopy to prevent capsule retention. This study aimed to evaluate the ability of magnetic resonance enterography (MRE) to predict patency capsule (PC) retention in patients with Crohn's disease and to identify the most predictive imaging features for retention.

METHODS

Fifty-seven patients prospectively underwent MRE and PC. Two radiologists predicted PC retention. Interrater reliability was determined by using Cohen's κ coefficient. The sensitivity, specificity, and positive and negative predictive values were calculated for the predictions. Evaluation of the imaging features was done using the t test and receiver-operating characteristics; t-tests were also performed on the clinical parameters.

RESULTS

The κ value for interrater reliability was 0.58. The sensitivity, specificity, PPV, and NPV for the predictions by the 2 radiologists were 92.3%, 59%, 40%, 96.3%, and 100%, 52.3%, 38.2%, 100%, respectively. The maximal stricture length (9.7 ± 3.66 cm vs 7.0 ± 3.08 cm, P = .04) and the number of prestenotic dilations (1.9 ± 1.07 vs 1.0 ± 1.38, P = .03) were associated with PC retention. The area under the receiver-operating characteristic curves was 0.69 for the maximal stricture length and 0.751 for the number of prestenotic dilations. The phenotype of the disease was the only clinical parameter significantly correlated with PC retention.

CONCLUSIONS

MRE has a high NPV and sensitivity for PC retention. When capsule retention is suggested by MRE, PC should be performed before the video capsule endoscopy examination. The maximal stricture length and the number of prestenotic dilations were found to be the most predictive imaging features for PC retention.

The longest duration of retention of a video capsule

An underweight 15-year-old boy had a video capsule endoscopy (VCE) to investigate iron deficient anaemia associated with elevated platelet and white cell counts. The suspicion was of subclinical small bowel Crohn's disease after the findings of a radiolabelled white cell scan. The VCE in May 2007 found patchy inflammation and superficial ulcers in the terminal ileum consistent with Crohn's disease. By March 2008, the patient remained asymptomatic but the capsule had not passed. He was treated with steroids to improve the inflammation and allow the capsule to pass. This was unsuccessful. Abdominal X-rays appeared to show that it was in the rectum. CT of the abdomen and pelvis in July 2012 showed that it was actually in the mid-distal ileum within a mass of inflamed and matted small bowel loops. He was last reviewed in March 2014. He has now retained the capsule asymptomatically for 6 years and 10 months.

Capsule endoscopy: a cause of late small bowel obstruction and perforation

Case Report. A 71-year-old man was admitted to the department of gastroenterology with diffuse abdominal pain. Through the previous 12 months, the patient had experienced episodes of vomiting and watery diarrhea of increasing intensity as well as weight loss. The patient was evaluated with ultrasound, MRI, and subsequently a capsule endoscopy. Six months later, the patient presented, and an abdominal CT-scan showed mechanical small bowel obstruction with suspicion of metallic foreign body and perforation. Laparotomy showed perforation, stenosis, and foreign body, approximately 5 cm from the ileocecal valve. A right hemicolectomy and distal ileectomy (60 cm) with an ileostomy were performed. On further inspection of resection, a capsule endoscope was found impacted in a stenosis. The ileostomy was later reversed without complications. Conclusion. It is important to be aware of the possibility of capsule retention, especially in patients with known or suspected Crohn's disease, due to the propensity of Crohn's disease to form stenosis of the bowel. In cases where a stenosis is suspected, it is warranted to perform a patency capsule swallow before subjecting the patient to a capsule endoscopy.

Shooting a moving target: use of real-time cine magnetic resonance imaging in assessment of the small bowel

The chronic nature of inflammatory bowel disease (IBD) creates a lifelong effect on the morbidity of children affected by the disease. The ability to confidently identify and characterize complications resulting from IBD in the pediatric patient is of critical importance. Magnetic resonance enterography (MRE) is especially valuable in the diagnostic assessment of IBD; however, precise elucidation of complications including strictures can be difficult with standard MRE sequences. The recent development of faster MRI pulse sequences provides rapid, real-time imaging of the intestinal tract. In this review, we describe how the addition of cine MRE confidently pinpoints areas of stricture, aids in lesion detection and diagnosis, and provides valuable information on intestinal motility.

Small bowel endoscopy in inflammatory bowel disease

Crohn disease (CD) is a chronic inflammatory bowel disease that affects the entire gastrointestinal tract but is most frequently localized to the large and small bowel. Small bowel endoscopy helps with the differential diagnosis of CD in suspected CD patients. Early diagnosis of CD is preferable for suspected CD conditions to improve chronic inflammatory infiltrates, fibrosis. Small bowel endoscopy can help with the early detection of active disease, thus leading to early therapy before the onset of clinical symptoms of established CD. Some patients with CD have mucosal inflammatory changes not in the terminal ileum but in the proximal small bowel. Conventional ileocolonoscopy cannot detect ileal involvement proximal to the terminal ileum. Small bowel endoscopy, however, can be useful for evaluating these small bowel involvements in patients with CD. Small bowel endoscopy by endoscopic balloon dilation (EBD) enables the treatment of small bowel strictures in patients with CD. However, many practical issues still need to be addressed, such as endoscopic findings for early detection of CD, application compared with other imaging modalities, determination of the appropriate interval for endoscopic surveillance of small bowel lesions in patients with CD, and long-term prognosis after EBD.

Double-balloon enteroscopy for mesenchymal tumors of small bowel: Nine years’ experience

AIM: To assess the value of double-balloon enteroscopy (DBE) for the diagnosis of gastrointestinal mesenchymal tumors (GIMTs) in the small bowel and clarify their clinical and endoscopic characteristics.

METHODS: A retrospective review in a total of 783 patients who underwent a DBE procedure from January 2003 to December 2011 was conducted. Data from patients with pathologically confirmed GIMTs were analyzed at a single tertiary center with nine years’ experience. The primary outcomes assessed included characteristics of patients with GIMTs, indications for DBE, overall diagnostic yield of GIMTs, endoscopic morphology, positive biopsy, comparison of diagnosis with capsule endoscopy, and subsequent interventional management.

RESULTS: GIMTs were identified and analyzed in 77 patients. The mean age was 47.74 ± 14.14 years (range: 20-77 years), with 63.6% being males. The majority of individuals presented with gastrointestinal bleeding, accounting for 81.8%, followed by abdominal pain, accounting for 10.4%. Small bowel pathologies were found in 71 patients, the detection rate was 92.2%. The diagnostic yield of DBE for GIMTs was 88.3%. DBE was superior to capsule endoscopy in the diagnosis of GIMTs (P = 0.006; McNemar’s χ² test). Gastrointestinal stromal tumor was the most frequent and leiomyoma was the second frequent GIMT. Single and focal lesions were typical of GIMTs, and masses with smooth or unsmooth surface were the most common in the small bowel. GIMTs were removed from all the patients surgically except one patient treated with endoscopic resection.

CONCLUSION: DBE is a safe and valuable procedure for patients with suspected GIMTs, and it provides an accurate position for subsequent surgical intervention.

Capsule endoscopy: new technology, old complication

Wireless capsule endoscopy is a new tool in the armamentarium of the gastroenterologist to evaluate the small bowel non-invasively. It allows improved diagnostic yield with low complication rates relative to traditional modalities. But this new technology has its own set of complications, some which can lead to significant morbidity. Here, we present a case of complete small bowel obstruction following a capsule endoscopy. A 65-year-old female with a long standing history of anemia and obscure gastrointestinal bleed presented to the Emergency Department 72 hours after a wireless capsule endoscopy procedure complaining of worsening abdominal pain, distension, and frequent vomiting. An X-ray was suggestive of complete distal small bowel obstruction with the capsule at the transition point of dilated proximal and collapsed distal small bowel. The patient was resuscitated and taken up for an explorative laparotomy where a short segment stricture was noted with the capsule endoscope caught proximal to it. The segment was resected and patient made an uneventful recovery. Wireless capsule endoscopy is now becoming the preferred method to image the small bowel. Our report illustrates the importance of appropriate patient selection and evaluation of functional patency of the small bowel may be with a contrast series prior to wireless capsule endoscopy to avoid any post procedural morbidity.

Small bowel diagnostics: current place of small bowel endoscopy

The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Until the end of the last century, the small bowel follow through was the primary diagnostic tool for suspected small bowel disease. In recent years capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computerized tomography and magnetic resonance enteroclysis or enterography have facilitated the diagnosis, monitoring, and management of patients with small bowel diseases. These technologies are complementary, each with its advantages and limitations. In the present article, we will discuss the different options and indications for modern diagnostic methods for visualization of the small bowel. We also try to provide a clinical rationale for the use of these different diagnostic options in less established, newly emerging, indications for small bowel evaluation.

Capsule impaction presenting as acute small bowel perforation: a case series

INTRODUCTION

Perforation caused by capsule endoscopy impaction is extremely rare and, at present, only five cases of perforation from capsule endoscopy impaction are reported in the literature.

CASE PRESENTATION

We report here two cases of patients with undiagnosed small bowel stenosis presenting with acute perforation after capsule endoscopy. Strictures in the small bowel were likely the inciting mechanism leading to acute small bowel obstruction and subsequent distension and perforation above the capsule in the area of maximal serosal tension.Case 1 was a 55-year-old Italian woman who underwent capsule endoscopy because of recurrent postprandial cramping pain and iron deficiency anemia, in the setting of negative imaging studies including an abdominal ultrasound, upper endoscopy, colonoscopy and small bowel follow-through radiograph. She developed a symptomatic bowel obstruction approximately 36 hours after ingestion of the capsule. Emergent surgery was performed to remove the capsule, which was impacted at a stenosis due to a previously undiagnosed ileal adenocarcinoma, leading to perforation.Case 2 was a 60-year-old Italian man with recurrent episodes of abdominal pain and diarrhea who underwent capsule endoscopy after conventional modalities, including comprehensive blood and stool studies, computed tomography, an abdominal ultrasound, upper endoscopy, colonoscopy, barium enema and small bowel follow-through, were not diagnostic. Our patient developed abdominal distension, acute periumbilical pain, fever and leukocytosis 20 hours after capsule ingestion. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed ileal Crohn's stricture, leading to perforation.

CONCLUSIONS

The present report shows that, although the risk of acute complication is very low, the patient should be informed of the risks involved in capsule endoscopy, including the need for emergency surgical exploration.

Small bowel perforation following capsule endoscopy: a case report

Small bowel perforation following a capsule endoscopy (CE) is a rare but dreadful complication. We report a CE induced small bowel perforation in a patient with Crohn's disease where preoperative investigations failed to reveal any strictures.

Outcomes after symptomatic capsule retention in suspected small bowel obstruction

BACKGROUND AND AIM

Capsule endoscopy (CE) has been proven to be a sensitive and a safe tool for the examination of the small bowel. However, careful patient selection is required to avoid complications, primarily capsule retention. The aims of this study were to evaluate the rate of capsule retention in patients with suspected chronic small bowel obstruction and to analyze the role and the impact of subsequent surgical intervention.

METHODOLOGY

Fifteen patients referred for CE with a clinical picture suggestive of chronic small bowel obstruction and with negative imaging studies were retrospectively analyzed.

RESULTS

Capsule retention occurred in three (20%) patients who developed symptoms of subacute obstruction and subsequently underwent surgery. Radiation enteritis, Crohn's disease, and an ileal tumor were demonstrated as the causes of the capsule retention in these patients. Surgical removal of the retained capsule was performed and the underlying small bowel disease was treated.

CONCLUSION

Capsule retention is a frequent complication of CE in patients with symptoms of chronic small bowel obstruction. Surgery, with the removal of the retained capsule, is proven to be beneficial in identifying the location of, and treating, the underlying disease in these patients.

Endoscopic approach to capsule endoscope retention

In recent years, wireless capsule endoscopy has become increasingly indicated and utilized in the diagnosis and management of small bowel disorders. As such, its most common complication, capsule retention, has become a more frequently encountered clinical entity. Historically, when medical management of capsule retention has failed, patients have been sent directly to surgery. However, recent advances in small bowel enteroscopy have demonstrated a high success rate and safety profile in retrieving retained capsules. These approaches appear to be a viable alternative to surgery in many clinical scenarios. This article discusses both standard and advanced endoscopic approaches to capsule retention, and presents an algorithmic approach to their utilization.

Capsule retention: a feared complication of wireless capsule endoscopy

Wireless capsule endoscopy is a simple, non-invasive technique for the visualization of the entire small bowel. It was introduced in clinical praxis in 2001 and has already become the method of choice for the investigation of small-bowel pathology. Capsule retention is a major complication, with an overall incidence of 1-2%, although reported rates vary widely from 0% to 21%, depending on the indication for the examination. This complication can occur at any level of the gastrointestinal tract and in most cases runs asymptomatically. However, symptomatic bowel obstruction requiring surgical or endoscopic removal of the impacted capsule can occur. Rarely, capsule retention can lead to intestinal perforation. Despite several years of experience with wireless capsule endoscopy, there is up to the present no safe means of predicting capsule retention. Radiological studies have a low diagnostic yield and tend to underestimate or overestimate small-bowel strictures. The role of the new generation patency capsule (Agile patency capsule) needs to be further documented. The experts agree that obtaining a careful history is perhaps the best single method to detect the possibility of retention.

Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review

BACKGROUND

Capsule endoscopy (CE) has been widely used in clinical practice.

OBJECTIVE

To provide systematically pooled results on the indications and detection, completion, and retention rates of small-bowel CE.

DESIGN

A systematic review.

MAIN OUTCOME MEASUREMENTS

We searched the PubMed database (2000-2008) for original articles relevant to small-bowel CE for the evaluation of patients with small-bowel signs and symptoms. Data on the total number of capsule procedures, the distribution of different indications for the procedures, the percentages of procedures with positive detection (detection rate), complete examination (completion rate), or capsule retention (retention rate) were extracted and/or calculated, respectively. In addition, the detection, completion, and retention rates were also extracted and/or calculated in relation to indications such as obscure GI bleeding (OGIB), definite or suspected Crohn's disease (CD), and neoplastic lesions.

RESULTS

A total of 227 English-language original articles involving 22,840 procedures were included. OGIB was the most common indication (66.0%), followed by the indication of only clinical symptoms reported (10.6%), and definite or suspected CD (10.4%). The pooled detection rates were 59.4%; 60.5%, 55.3%, and 55.9%, respectively, for overall, OGIB, CD, and neoplastic lesions. Angiodysplasia was the most common reason (50.0%) for OGIB. The pooled completion rate was 83.5%, with the rates being 83.6%, 85.4%, and 84.2%, respectively, for the 3 indications. The pooled retention rates were 1.4%, 1.2%, 2.6%, and 2.1%, respectively, for overall and the 3 indications.

LIMITATIONS

Inclusion and exclusion criteria were loosely defined.

CONCLUSIONS

The pooled detection, completion, and retention rates are acceptable for total procedures. OGIB is the most common indication for small-bowel CE, with a high detection rate and low retention rate. In addition, angiodysplasia is the most common finding in patients with OGIB. A relatively high retention rate is associated with definite or suspected CD and neoplasms.

Acute small bowel perforation after wireless capsule endoscopy in a patient with Crohn's disease: a case report

Introduction

Wireless capsule endoscopy is an important tool for minimally invasive evaluation of the small bowel, allowing improved diagnostic yield with low complication rates relative to traditional modalities. Recently however, reports on small bowel perforation after wireless capsule endoscopy have surfaced. Here we present the first case of acute small bowel perforation in a middle-aged male in the United States.

Case presentation

A 58-year-old male with a presumed quiescent history of Crohn’s Disease presented to the Emergency Department in a septic state 48 hours after a wireless capsule endoscopy procedure complaining of abdominal pain, distension, and frequent emesis. A computed tomography scan of the abdomen was suggestive of small bowel perforation and ischemic enteritis. The patient was adequately resuscitated and taken to the operating room for an ileocecectomy and extensive resection of the small bowel. Pathology of the resected specimen revealed an ileal stricture and associated necrotizing ileitis, and a perforation just proximal to the stricture.

Conclusion

Wireless capsule endoscopy remains the preferred endoscopic imaging method of the small bowel. This case illustrates the importance of appropriate patient selection and evaluation of functional patency of the small bowel prior to wireless capsule endoscopy, especially with the growing role of this procedure in the evaluation of inflammatory bowel disease.

Comparison of detectability of small-bowel lesions between capsule endoscopy and double-balloon endoscopy for patients with suspected small-bowel disease

BACKGROUND

There are many reports of the usefulness of capsule endoscopy (CE) or double-balloon endoscopy (DBE) for the detection of small-bowel disease. However, there are few reports that compared CE and DBE.

OBJECTIVE

To determine whether CE or DBE better detects small-bowel lesions in patients with suspected small-bowel disease.

DESIGN

A prospective single-center study.

SETTING

Department of Endoscopy, Hiroshima University Hospital.

MAIN OUTCOME MEASUREMENTS

Rates of CE and DBE detection of small-bowel lesions.

PATIENTS

Seventy-six consecutive patients (47 men, 29 women; mean age 56.0 years) who underwent both CE and DBE.

METHODS

CE was performed before DBE. DBEs were performed within 1 week, by both retrograde and antegrade approaches so that the entire small bowel could be examined, if possible.

RESULTS

Small-bowel lesions were detected by CE in 42 patients (55.3%) and by DBE in 46 patients (60.5%). The difference was not significant (P = .45). Total enteroscopy was achieved by both examinations in 35 patients, and small-bowel lesions were detected by both examinations in 21 of the 35 patients (60.0%). Agreement between results of the 2 examinations was good (kappa = 0.76).

LIMITATION

The main indication for examinations was not the same.

CONCLUSIONS

CE and DBE are nearly equal in their ability to detect small-bowel lesions if the entire small bowel is examined.

Recent progress in clinical applications of capsule endoscopy

Capsule endoscopy has been widely used since it was approved by the Food & Drug Administration in the USA in 2001. It plays an important role in the investigation of obscure gastrointestinal bleeding, Crohn's disease and complications of coeliac disease, and surveillance of polyposis syndromes in adults. Despite a lag in its use in paediatrics, capsule endoscopy offers an accurate and effective means of investigating the small bowel in children. It has opened up new horizons and provided a noninvasive approach to identify occult lesions in the small bowel. This article reviews the recent advance in clinical applications of capsule endoscopy.

Safety, reliability and limitations of the given patency capsule in patients at risk of capsule retention: a 3-year technical review

INTRODUCTION

The patency capsule may prevent capsule retention in high-risk patients. However data on its use in routine clinical practice is limited.

METHODS

Patients referred to our institution between Feb-04 and Jan-07 were reviewed. The following data was collected: presenting symptoms; medical/surgical history; medication; radiology; patency/video capsule result; subsequent investigations; clinical outcomes.

RESULTS

373 patients were referred. In 315 (84%) 'low-risk' patients (no patency capsule): delayed transit occurred in three, with no cases of capsule retention. In 58 (16%) 'high risk' patients (patency capsule): asymptomatic retention occurred in eight, all with pathology despite normal prior barium studies in six; in four cases patency location was incorrectly assessed radiologically, leading to video capsule retention and surgery in one.

DISCUSSION

Most patients can safely undergo capsule endoscopy without a patency capsule. The patency capsule appears safe and is indicative of pathology when retained. Assessment of patency capsule location post ingestion can be difficult, and if barium radiology is equivocal a limited abdominal computed tomography (CT) scan is suggested.

Capsule endoscopy in neoplastic diseases

Until recently, diagnosis and management of small-bowel tumors were delayed by the difficulty of access to the small bowel and the poor diagnostic capabilities of the available diagnostic techniques. An array of new methods has recently been developed, increasing the possibility of detecting these tumors at an earlier stage. Capsule endoscopy (CE) appears to be an ideal tool to recognize the presence of neoplastic lesions along this organ, since it is non-invasive and enables the entire small bowel to be visualized. High-quality images of the small-bowel mucosa may be captured and small and flat lesions recognized, without exposure to radiation. Recent studies on a large population of patients undergoing CE have reported small-bowel tumor frequency only slightly above that reported in previous surgical series (range, 1.6%-2.4%) and have also confirmed that the main clinical indication to CE in patients with small-bowel tumors is obscure gastrointestinal (GI) bleeding. The majority of tumors identified by CE are malignant; many were unsuspected and not found by other methods. However, it remains difficult to identify pathology and tumor type based on the lesion’s endoscopic appearance. Despite its limitations, CE provides crucial information leading in most cases to changes in subsequent patient management. Whether the use of CE in combination with other new diagnostic (MRI or multidetector CT enterography) and therapeutic (Push-and-pull enteroscopy) techniques will lead to earlier diagnosis and treatment of these neoplasms, ultimately resulting in a survival advantage and in cost savings, remains to be determined through carefully-designed studies.

Correlation of magnetic resonance enteroclysis (MRE) and wireless capsule endoscopy (CE) in the diagnosis of small bowel lesions in Crohn's disease

BACKGROUND

The aim was to evaluate and compare the diagnostic performance of magnetic resonance enteroclysis (MRE) and wireless video capsule endoscopy (CE) in detecting and classifying small bowel Crohn's disease (CD) proximal to the terminal ileum.

METHODS

Nineteen patients with histologically proven CD (M:F = 13:6; mean 34 years, range 17-65) were prospectively included in the study when presenting with clinical signs suggesting stricturing or inflammatory lesions of CD in the proximal small bowel. All patients underwent MRE with an infusion technique and were then admitted to CE.

RESULTS

As for the presence or absence of pathology, results of MRE and CE were in total agreement for 44/52 (85%) evaluated segments. In judging lesion severity, MRE and CE yielded identical results in 29/52 (56%) segments. MRE underestimated pathology in 7/52 (14%) segments and revealed more severe pathology in 6/52 (12%) segments. CE identified subtle (n = 7) or severe (n = 2) mucosal pathology while MRE was normal. CE entirely missed severe inflammatory mural changes depicted in MRE in 1/52 (2%) segments.

CONCLUSIONS

MRE and CE show good correlation in the detection and localization of inflammatory bowel disease. As for disease activity, MRE is inferior in the detection of superficial mucosal disease but reliably discloses the presence of severe inflammatory changes within the bowel wall and beyond, which may be underestimated from the endoscopic aspect of the mucosal surface. MRE helps to rule out severe stenoses that should be referred for immediate surgical intervention. In conclusion, both modalities are complementary and MRE should be used in more severe cases of Crohn's disease and in patients who might have involvement beyond the mucosa of the small bowel.

Capsule endoscopy in Crohn's disease - Indications and reservations 2008

Capsule endoscopy (CE) was found to be an effective tool in diagnosis of small bowel pathology. This review will focus on its role in Crohn's disease. Its role in patients with suspected Crohn's disease (CD) is described. CE has an established role for diagnosing CD when other tests are negative, though it is not a first line investigative tool in these patients. Over diagnosis is of concern. Its use in established CD remains an open question. It can provide exact mapping of small bowel disease before surgery, and might have impact on the treatment of the disease. It may have role in monitoring mucosal healing, which is becoming a target of therapy, and may help establish the exact diagnosis in a limited group of patients with indeterminate colitis. Retention of CE might occur. It is of low rate in patients with suspected CD and higher in patients with known CD but clinical obstruction is extremely rare. Economic considerations are a limit to a wider application of the CE.

Small bowel capsule endoscopy in 2007: indications, risks and limitations

Capsule endoscopy has revoluzionized the study of the small bowel by providing a reliable method to evaluate, endoscopically, the entire small bowel. In the last six years several papers have been published exploring the possible role of this examination in different clinical conditions. At the present time capsule endoscopy is generally recommended as a third examination, after negative bidirectional endoscopy, in patients with obscure gastrointestinal bleeding. A growing body of evidence suggests also an important role for this examination in other clinical conditions such as Crohn's disease, celiac disease, small bowel polyposis syndromes or small bowel tumors. The main complication of this examination is the retention of the device at the site of a previously unknown small bowel stricture. However there are also some other open issues mainly due to technical limitations of this tool (which is not driven from remote control, is unable to take biopsies, to insufflate air, to suck fluids or debris and sometimes to correctly size and locate lesions). The recently developed double balloon enteroscope, owing to its capability to explore a large part of the small bowel and to take targeted biopsies, although being invasive and time consuming, can overcome some limitations of capsule endoscopy. At the present time, in the majority of clinical conditions (i.e. obscure GI bleeding), the winning strategy seems to be to couple these two techniques to explore the small bowel in a painless, safe and complete way (with capsule endoscopy) and to define and treat the lesions identified (with double balloon enteroscopy).

Wireless capsule endoscopy: indications, limitations, and future challenges

Wireless capsule endoscopy is one of the recent inventions that has made an impact in the diagnostic work-up of gastrointestinal diseases, mainly in small intestinal pathology, the part of the gut that cannot be totally visualized by upper and lower gastrointestinal endoscopy. Since the first report documenting the use of capsule endoscopy, many adult clinical trials have taken place. Although the Food and Drug Administration approved the use of the capsule in children (ages 10-18 years) in October 2003, few small clinical trials exploring the diagnostic yield of capsule endoscopy in pediatric populations have been published.

Small bowel capsule endoscopy in 2007: indications, risks and limitations

Capsule endoscopy has revoluzionized the study of the small bowel by providing a reliable method to evaluate, endoscopically, the entire small bowel. In the last six years several papers have been published exploring the possible role of this examination in different clinical conditions. At the present time capsule endoscopy is generally recommended as a third examination, after negative bidirectional endoscopy, in patients with obscure gastrointestinal bleeding. A growing body of evidence suggests also an important role for this examination in other clinical conditions such as Crohn's disease, celiac disease, small bowel polyposis syndromes or small bowel tumors. The main complication of this examination is the retention of the device at the site of a previously unknown small bowel stricture. However there are also some other open issues mainly due to technical limitations of this tool (which is not driven from remote control, is unable to take biopsies, to insufflate air, to suck fluids or debris and sometimes to correctly size and locate lesions). The recently developed double balloon enteroscope, owing to its capability to explore a large part of the small bowel and to take targeted biopsies, although being invasive and time consuming, can overcome some limitations of capsule endoscopy. At the present time, in the majority of clinical conditions (i.e. obscure GI bleeding), the winning strategy seems to be to couple these two techniques to explore the small bowel in a painless, safe and complete way (with capsule endoscopy) and to define and treat the lesions identified (with double balloon enteroscopy).

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.