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Stewart J, Fleishman NR, Staggs VS, Thomson M, Stoecklein N, Lawson CE, Washburn MP, Umar S, Attard TM. Small Intestinal Polyp Burden in Pediatric Peutz-Jeghers Syndrome Assessed through Capsule Endoscopy: A Longitudinal Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1680. [PMID: 37892343 PMCID: PMC10605554 DOI: 10.3390/children10101680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/22/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023]
Abstract
The management of pediatric Peutz-Jeghers Syndrome (PJS) focuses on the prevention of intussusception complicating small intestinal (SI) polyposis. This hinges on the accurate appraisal of the polyp burden to tailor therapeutic interventions. Video Capsule Endoscopy (VCE) is an established tool to study SI polyps in children, but an in-depth characterization of polyp burden in this population is lacking. Methods: We performed a retrospective longitudinal cross-sectional analysis of VCE studies in pediatric PJS patients at our institution (CMKC) from 2010 to 2020. Demographic, clinical, and VCE findings reported by three reviewers in tandem were accrued. Polyp burden variables were modeled as functions of patient and study characteristics using linear mixed models adjusted for clustering. Results: The cohort included 15 patients. The total small bowel polyp count and largest polyp size clustered under 30 polyps and <20 mm in size. Luminal occlusion correlated closely with the estimated polyp size. Polyp distribution favored proximal (77%) over distal (66%) small bowel involvement. The adjusted largest polyp size was greater in males. Double Balloon Enteroscopy was associated with a decreased polyp burden. Conclusions: The polyp burden in pediatric PJS patients favors the proximal third of the small intestine, with relatively small numbers and a polyp size amenable to resection through enteroscopy. Male gender and older age were related to an increased polyp burden.
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Affiliation(s)
- Jeremy Stewart
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center, Children’s Medical Center, Dallas, TX 75235, USA
| | - Nathan R. Fleishman
- Division of Gastroenterology, Levine Children’s Hospital, Charlotte, NC 28203, USA
| | - Vincent S. Staggs
- Biostatistics and Epidemiology Core, Division of Health Services and Outcomes Research, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Mike Thomson
- Department of Paediatric Gastroenterology, Sheffield Children’s Hospital NHS Foundation Trust, Sheffield University, Sheffield S10 2TH, UK
| | - Nicole Stoecklein
- Division of Gastroenterology, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Caitlin E. Lawson
- Division of Genetics, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Michael P. Washburn
- Department of Cancer Biology, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Shahid Umar
- Department of Surgery, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Thomas M. Attard
- Division of Gastroenterology, Children’s Mercy Hospital, Kansas City, MO 64108, USA
- University of Missouri–Kansas City School of Medicine, 2464 Charlotte St, Kansas City, MO 64108, USA
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2
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Limsrivilai J, Chaemsupaphan T, Khamplod S, Srisajjakul S, Kositamongkol C, Phisalprapa P, Maipang K, Kaosombatwattana U, Pausawasdi N, Charatcharoenwitthaya P, Leelakusolvong S, Pongprasobchai S. "MURAL" model to predict bleeding from mural-based lesions in potential small bowel bleeding may improve diagnostic capability and decrease cost. Medicine (Baltimore) 2022; 101:e31989. [PMID: 36482571 PMCID: PMC9726317 DOI: 10.1097/md.0000000000031989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In potential small bowel bleeding, video capsule endoscopy (VCE) is excellent to detect mucosal lesions, while mural-based lesions are better detected by computed tomography enterography (CTE). A predictive tool to identify mural-based lesions should guide selecting investigations. In this retrospective study, we developed and validated the "MURAL" model based on logistic regression to predicts bleeding from mural-based lesions. Cost-effectiveness analysis comparing diagnostic strategy among VCE, CTE, and MURAL model was performed. Of 296 patients, 196 and 100 patients were randomly included in the derivative and validation cohorts, respectively. The MURAL model comprises 5 parameters: age, presence of atherosclerosis, chronic kidney disease, antiplatelet use, and serum albumin level. The area under the receiver operating characteristic curve was 0.778 and 0.821 for the derivative and validation cohorts, respectively. At a cutoff value of 24.2%, the model identified mural-based lesions with 70% sensitivity and 83% specificity in the validation cohort. Cost-effectiveness analysis revealed that application of the MURAL model demonstrated a comparable missed lesion rate but had a lower missed tumor rate, and lower cost compared to VCE strategy. The model for predicting mural-based lesions provide some guidance in investigative decision-making, which may improve diagnostic efficiency and reduce costs.
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Affiliation(s)
- Julajak Limsrivilai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanaboon Chaemsupaphan
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sipawath Khamplod
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sitthipong Srisajjakul
- Department of Radiology, Division of Diagnostic Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chayanis Kositamongkol
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pochamana Phisalprapa
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kochakon Maipang
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Uayporn Kaosombatwattana
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Somchai Leelakusolvong
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supot Pongprasobchai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- * Correspondence: Supot Pongprasobchai, Associate Professor of Medicine, Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand (e-mail: )
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3
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Small Bowel Malignancies in Patients Undergoing Capsule Endoscopy for Iron Deficiency Anemia. Diagnostics (Basel) 2021; 12:diagnostics12010091. [PMID: 35054257 PMCID: PMC8774472 DOI: 10.3390/diagnostics12010091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/14/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022] Open
Abstract
Small bowel malignancies are rare and usually asymptomatic or symptoms are nonspecific. Therefore, small bowel tumors are difficult to diagnose. In patients with iron deficiency anemia (IDA) who have negative bidirectional endoscopy results, the small bowel may be considered the source of bleeding. However, in asymptomatic IDA patients with negative bidirectional endoscopy results, evidence supporting the routine use of capsule endoscopy (CE) is insufficient. CE can be considered in selected patients with recurrent or persistent IDA. The frequency of small bowel malignancies is low in patients undergoing CE for IDA, but the usefulness of CE for the diagnosis of small bowel malignancies in younger age groups with IDA has been reported. For patients with risk factors for small bowel malignancy, investigation of the small bowel should be considered. Efforts should be made to prevent adverse events, such as capsule retention or capsule aspiration, through meticulous history taking and endoscopic capsule delivery as necessary.
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4
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Skamnelos A, Lazaridis N, Vlachou E, Koukias N, Apostolopoulos P, Murino A, Christodoulou D, Despott EJ. The role of small-bowel endoscopy in inflammatory bowel disease: an updated review on the state-of-the-art in 2021. Ann Gastroenterol 2021; 34:599-611. [PMID: 34475730 PMCID: PMC8375652 DOI: 10.20524/aog.2021.0652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/14/2021] [Indexed: 12/11/2022] Open
Abstract
The impact of small-bowel (SB) capsule endoscopy and device-assisted enteroscopy on clinical practice, since their introduction 2 decades ago, has been remarkable. These disruptive technologies have transformed the investigation and management of SB pathology and now have a firmly established place in guidelines and clinical algorithms. Furthermore, recent years have witnessed innovations, driven by the demand of new goals in the management of inflammatory bowel disease (IBD), such as mucosal healing and evolving strategies based on tight monitoring and accelerated escalation of care. These developments in SB endoscopy have also been paralleled by refinement in dedicated radiological SB imaging technologies. This updated review highlights the current state of the art and more recent innovations with a focus on their role in IBD.
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Affiliation(s)
- Alexandros Skamnelos
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott).,Division of Gastroenterology, University Hospital and Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece (Alexandros Skamnelos, Dimitrios Christodoulou)
| | - Nikolaos Lazaridis
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott).,Genesis Hospital of Thessaloniki, Thessaloniki, Greece (Nikolaos Lazaridis)
| | - Erasmia Vlachou
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott).,Army Share Funds Hospital (NIMTS), Athens, Greece (Erasmia Vlachou, Periklis Apostolopoulos)
| | - Nikolaos Koukias
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott).,Department of Gastroenterology, University Hospital of Patras, Patras, Greece (Nikolaos Koukias)
| | - Periklis Apostolopoulos
- Army Share Funds Hospital (NIMTS), Athens, Greece (Erasmia Vlachou, Periklis Apostolopoulos)
| | - Alberto Murino
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott)
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital and Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece (Alexandros Skamnelos, Dimitrios Christodoulou)
| | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott)
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5
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Shuai S, Zhifang Z, Yuming W, Hong J, Chao S, Kui J, Bangmao W. Clinical Scoring Systems in Predicting the Outcomes of Small Bowel Bleeding. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2021; 32:493-499. [PMID: 34405815 PMCID: PMC8975372 DOI: 10.5152/tjg.2020.19458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/19/2019] [Indexed: 06/13/2023]
Abstract
BACKGROUND The aim was to assess the clinical Glasgow-Blatchford score (GBS), Rockall score (CRS), and AIMS65 score in predicting outcomes (rebleeding, need for intervention, and length of stay) among patients with small bowel hemorrhage. METHODS We conducted a retrospective study of patients with small bowel bleeding (SBB). Rebleeding, need for intervention, and length of stay was investigated by 3 scoring systems. The area under the receiver operator characteristic curve was used to analyze the performance of 3 scoring systems. RESULTS Among 162 included patients, the scores of rebleeding, intervention, and length of stay ≥10 days groups were higher than no rebleeding, non-intervention, and length of stay <10 days groups, respectively (P < .05). The CRS, GBS, and AIMS65 scoring systems demonstrated statistically significant difference in predicting rebleeding (AUROC 0.693 vs. 0.790 vs. 0.740; all P < .01), intervention (AUROC: 0.726 vs. 0.825 vs. 0.773; all P < .01) and length of stay (AUROC 0.651 vs. 0.631 vs. 0.635; all P < .05). Higher cut-off scores achieved better sensitivity/specificity [rebleeding (CRS > 2, GBS > 7, AIMS65 > 0); need for intervention (CRS > 2, GBS > 7, AIMS65 > 0); length of stay (CRS > 0, GBS > 7, AIMS65 > 1)] in the risk stratification. CONCLUSIONS The GBS system is reliable to be recommended for routine use in predicting rebleeding and the need for intervention for early decision making in patients with SBB. The 3 scoring systems are poorly useful in predicting length of stay.
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Affiliation(s)
- Su Shuai
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Zhang Zhifang
- Department of Neurology, Tianjin Xiqing Hospital, Tianjin, People’s Republic of China
| | - Wang Yuming
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Jin Hong
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Sun Chao
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Jiang Kui
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Wang Bangmao
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
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6
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Rosa B, Margalit-Yehuda R, Gatt K, Sciberras M, Girelli C, Saurin JC, Cortegoso Valdivia P, Cotter J, Eliakim R, Caprioli F, Baatrup G, Keuchel M, Ellul P, Toth E, Koulaouzidis A. Scoring systems in clinical small-bowel capsule endoscopy: all you need to know! Endosc Int Open 2021; 9:E802-E823. [PMID: 34079861 PMCID: PMC8159625 DOI: 10.1055/a-1372-4051] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/26/2020] [Indexed: 02/08/2023] Open
Abstract
AbstractCapsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2
3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4
5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8
9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.
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Affiliation(s)
- Bruno Rosa
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal
- ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Reuma Margalit-Yehuda
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Kelly Gatt
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Carlo Girelli
- Department of Internal Medicine, Gastroenterology & Digestive Endoscopy, Hospital of Busto Arsizio, Italy
| | - Jean-Christophe Saurin
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-Gastro-Entérologie et d'Endoscopie Digestive, Lyon, France
| | - Pablo Cortegoso Valdivia
- Gastroenterology & Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Jose Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho-Braga. Portugal
- ICVS/3B’s, PT Government Associate Laboratory – Braga/Guimarães, Portugal.
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Flavio Caprioli
- Unit of Gastroenterology and Endoscopy, Fondazione IRCCS Cà Granda, Ospedale Policlinico di Milano, Milan, Italy
| | - Gunnar Baatrup
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Martin Keuchel
- Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Pierre Ellul
- Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Ervin Toth
- Skåne University Hospital, Lund University, Malmö, Sweden
| | - Anastasios Koulaouzidis
- Endoscopy Unit, The Royal Infirmary of Edinburgh, Scotland, UK
- Department of Social Medicine & Public Health, Pomeranian Medical University, Szczecin, Poland
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Negative Video Capsule Endoscopy Had a High Negative Predictive Value for Small Bowel Lesions, but Diagnostic Capability May Be Lower in Young Patients with Overt Bleeding. Can J Gastroenterol Hepatol 2021; 2021:8825123. [PMID: 34036087 PMCID: PMC8123999 DOI: 10.1155/2021/8825123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 01/18/2021] [Accepted: 04/28/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Patients with potential small bowel bleeding (PSBB) who have negative results of video capsule endoscopy (VCE), clinical course, rate of rebleeding, and missed lesions with their predictors are essential for further management decision. METHODS This retrospective study included patients presenting with PSBB who had negative VCE findings between January 2008 and December 2016. All patients had to have at least two years of follow-up data to be included. Patients with <2 years of follow-up in their medical record were interviewed by telephone to determine if any unrecorded rebleeding episodes occurred. RESULTS One hundred forty-two patients were included. The mean age was 60.9 years, and 52.8% were male. Eighty-one patients presented with overt bleeding. The median duration of follow-up was 5.08 years. During the follow-up period, 30 patients experienced rebleeding. The cumulative rate of rebleeding at 1, 2, and 5 years was 10.0%, 14.3%, and 22.4%, respectively. Multivariate analysis showed nonsteroidal anti-inflammatory drugs (NSAIDs) and presentation of overt bleeding to be independent predictors of rebleeding. There were only nine small bowel lesions (6.3%) missed by VCE. These nine patients, compared with others, were significantly younger and tended to present with overt bleeding. CONCLUSION Rebleeding was not uncommon in PSBB after negative VCE; however, the rate of missing small bowel lesions was low. Nonetheless, further investigations may be considered in young patients who present with overt bleeding.
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Yoo AY, Lee BJ, Kim WS, Kim SM, Kim SH, Joo MK, Kim HJ, Park JJ. Clinicopathological Features of Small Bowel Tumors Diagnosed by Video Capsule Endoscopy and Balloon-Assisted Enteroscopy: A Single Center Experience. Clin Endosc 2020; 54:85-91. [PMID: 32892518 PMCID: PMC7939772 DOI: 10.5946/ce.2020.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/20/2020] [Indexed: 02/06/2023] Open
Abstract
Background/Aims Small bowel malignancies often present a diagnostic challenge due to their relative rarity and nonspecific clinical symptoms. However, technical developments in endoscopic instruments, including video capsule endoscopy (VCE) and enteroscopy, have allowed for the visualization of the entire small bowel. This study aimed to investigate the clinicopathological features of small bowel malignant tumors diagnosed by VCE and double-balloon enteroscopy (DBE) in a single tertiary center.
Methods We retrospectively analyzed VCE and DBE findings from Korea University Guro Hospital from January 2010 through September 2018.
Results A total of 510 VCE and 126 DBE examinations were performed in 438 patients. Small bowel malignancies were diagnosed in 28 patients (15 males; mean age, 61.0 years; range, 42 to 81 years). Among them, 8 had lymphoma, 8 had primary adenocarcinoma, 7 had gastrointestinal stromal tumor (GIST) and 5 had metastatic cancer. Abdominal pain and obstructive symptoms were the most common findings in metastatic cancers (4/5, 80%). On the other hand, obscure gastrointestinal bleeding was the most common symptom of GIST (6/7, 85.7%) and adenocarcinoma (3/8, 37.5%).
Conclusions Approximately 6% of the patients who underwent either VCE or DBE were diagnosed with small bowel malignancy. These findings demonstrated the different clinical characteristics among small bowel malignancies and merit further study.
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Affiliation(s)
- Ah Young Yoo
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University, College of Medicine, Seoul, Korea
| | - Beom Jae Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University, College of Medicine, Seoul, Korea
| | - Won Shik Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University, College of Medicine, Seoul, Korea
| | - Seong Min Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University, College of Medicine, Seoul, Korea
| | - Seung Han Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University, College of Medicine, Seoul, Korea
| | - Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University, College of Medicine, Seoul, Korea
| | - Hyo Jung Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University, College of Medicine, Seoul, Korea
| | - Jong-Jae Park
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University, College of Medicine, Seoul, Korea
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9
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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10
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Masselli G, Guida M, Laghi F, Polettini E, Gualdi G. Magnetic Resonance of Small Bowel Tumors. Magn Reson Imaging Clin N Am 2019; 28:75-88. [PMID: 31753238 DOI: 10.1016/j.mric.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Tumors of the small intestine represent less than 5% of all gastrointestinal tract neoplasms. Magnetic resonance (MR) imaging is rapidly increasing clinical acceptance to evaluate the small bowel and can be the initial imaging method to investigate small bowel diseases. MR examinations may provide the first opportunity to detect and characterize tumors of the small bowel. Intraluminal and extraluminal MR findings, combined with contrast enhancement and functional information, allow accurate diagnoses and consequently characterization of small bowel neoplasms. This article describes the MR findings of primary small bowel neoplasms and the MR findings for the differential diagnosis are discussed.
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Affiliation(s)
- Gabriele Masselli
- Radiology Department, Umberto I Hospital Sapienza University, Viale del Policlinico 155, Rome 00161, Italy.
| | - Marianna Guida
- Radiology Department, Umberto I Hospital Sapienza University, Viale del Policlinico 155, Rome 00161, Italy
| | - Francesca Laghi
- Radiology Department, Umberto I Hospital Sapienza University, Viale del Policlinico 155, Rome 00161, Italy
| | - Elisabetta Polettini
- Radiology Department, Umberto I Hospital Sapienza University, Viale del Policlinico 155, Rome 00161, Italy
| | - Gianfranco Gualdi
- Radiology Department, Umberto I Hospital Sapienza University, Viale del Policlinico 155, Rome 00161, Italy
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Xavier S, Rosa B, Monteiro S, Arieira C, Magalhães R, Cúrdia Gonçalves T, Boal Carvalho P, Magalhães J, Moreira MJ, Cotter J. Bowel preparation for small bowel capsule endoscopy - The later, the better! Dig Liver Dis 2019; 51:1388-1391. [PMID: 31122824 DOI: 10.1016/j.dld.2019.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 04/08/2019] [Accepted: 04/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND In small bowel capsule endoscopy (SBCE), the presence of residue may compromise diagnostic accuracy. AIMS To assess differences in quality of visualisation and diagnostic yield of SBCE using 3 different preparation protocols. METHODS Prospective, randomized, blind, pilot study. Protocol A:Clear liquids diet the day before the examination with fasting from 8p.m.; Protocol B:Protocol A + 2 pouches of Moviprep®(polyethylene glycol electrolyte solution + sodium ascorbate) in 1 L of water from 8p.m. of the day before the examination; Protocol C: Protocol A + 2 pouches of Moviprep® in 1 L of water consumed after real-time confirmation of capsule arrival at small bowel. Small bowel preparation was classified by two experienced physicians, considering the percentage of the examination during which mucosal observation was adequate: Excellent(>90%); Good(90-75%); Fair(75-50%); Poor(<50%). RESULTS 101 patients randomized to the 3 protocols (A 37, B 31, C 33 patients). Protocol C had an excellent/good small bowel preparation in a higher percentage of examinations for both readers(Reader 1-A:37.8% vs B:45.2% vs C:78.8%, p = 0.002 and Reader 2 -A:37.8% vs B:41.9% vs C:75.8%, p = 0.003). Also, protocol C had a higher detection of angioectasia (A:5.4% vs B:9.7% vs C:27.3%, p = 0.022). CONCLUSIONS The administration of Moviprep® after the capsule had reached the small bowel was associated with a better small bowel preparation and a higher detection of angioectasia.
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Affiliation(s)
- S Xavier
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal.
| | - B Rosa
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - S Monteiro
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - C Arieira
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - R Magalhães
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - T Cúrdia Gonçalves
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - P Boal Carvalho
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - J Magalhães
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - M J Moreira
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - J Cotter
- Hospital Senhora da Oliveira, Guimarães - Gastroenterology Department, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
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Smith PJ, Patel T, Reading N, Giaslakiotis K, Hoque S. Masquerading in the midgut: a rare diagnosis in a patient with recurrent abdominal pain. Frontline Gastroenterol 2019; 11:420-422. [PMID: 32879725 PMCID: PMC7447279 DOI: 10.1136/flgastro-2019-101222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/31/2019] [Accepted: 06/13/2019] [Indexed: 02/04/2023] Open
Abstract
A 38-year-old woman who had been previously diagnosed with irritable bowel syndrome was seen in the outpatient clinic with a 2-year history of intermittent cramp-like abdominal pain which was often followed by watery diarrhoea. She had presented several times previously to the emergency department with episodes of severe pain and collapse although on arrival examination findings were mostly unremarkable other than some mild lower abdominal tenderness. On each occasion, the symptoms resolved spontaneously with conservative management. She had been extensively investigated by her general practitioner to establish the cause of her symptoms but all laboratory findings, cross-sectional imaging, ultrasound and oesophagogastroduodenoscopy to date were unremarkable. After being seen in gastroenterology outpatients' clinic, a colonoscopy was performed and was described as being macroscopically normal but microscopic evaluation of colonic biopsies suggested a possible 'resolving infection'. She was treated symptomatically, but within 6 months she represented to hospital with progressively worsening symptoms of severe abdominal pain, now associated with vomiting, followed by watery diarrhoea and then resolution of the symptoms. An abdominal CT scan was performed which showed a small intraluminal-filling defect in the mid-terminal ileum. A wireless capsule endoscopy was organised to further characterise the lesion although this was reported as showing no abnormality. Prior to any further outpatient investigations, she represented as an emergency to hospital in small bowel obstruction, underwent further cross-sectional imaging followed by surgical resection of the lesion. Histological characterisation revealed a small bowel inflammatory fibroid polyp.
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Affiliation(s)
- Philip J Smith
- Department of Gastroenterology, Whipps Cross University Hospital NHS Trust, London, London, UK
| | - Trusha Patel
- Department of Gastroenterology, Whipps Cross University Hospital NHS Trust, London, London, UK
| | - Nicholas Reading
- Department of Radiology, Whipps Cross University Hospital NHS Trust, London, London, UK
| | | | - Sami Hoque
- Department of Gastroenterology, Whipps Cross University Hospital NHS Trust, London, London, UK
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13
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Robertson AR, Yung DE, Douglas S, Plevris JN, Koulaouzidis A. Repeat capsule endoscopy in suspected gastrointestinal bleeding. Scand J Gastroenterol 2019; 54:656-661. [PMID: 31017489 DOI: 10.1080/00365521.2019.1606932] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: This study aims to review the utility of repeat capsule endoscopy (CE) with on-going concern of small bowel (SB) bleeding following initial SB investigation with CE. Materials and methods: A specifically designed database of CE examinations performed over 13 years, with hospital records, was retrospectively interrogated for patients undergoing multiple CEs to investigate iron deficiency anaemia (IDA) or suspected SB bleeding. Results: 1335/2276 (58.7%) of CEs were performed to investigate IDA or SB bleeding; 92 were repeat CEs carried out for ongoing clinical concern. The median time interval between initial and repeat CE procedures was 466.5 (range 1-3066) days. Twenty-four patients had initially normal CE; on repeat examination, abnormalities were detected in 11/24 (45.8%). 3/21 (14.2%) of patients with angioectasia on first CE had alternative causes for IDA or GI bleeding detected on repeat CE. Six patients with active bleeding, without an identifiable source on initial CE, undergoing repeat CE had a cause isolated in 5/6 (83.3%). Changing CE device did not affect diagnostic yield (DY) compared to repeat CE using the same device (27.5% to 26.8%). Conclusions: It is known that CE can miss clinically relevant and serious lesions. Our results suggest that patients with an initially negative or inconclusive CE frequently have a cause of SB bleeding detected on repeat CE. The DY of repeat CE is highest in those with bleeding on their initial CE (83.3%) and lower in those with initially normal examinations (45.8%) or when an alternative cause, such as angioectasia is seen (14.2%).
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Affiliation(s)
- A R Robertson
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
| | - D E Yung
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
| | - S Douglas
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
| | - J N Plevris
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
| | - A Koulaouzidis
- a Department of Gastroenterology , Royal Infirmary of Edinburgh , Edinburgh , Scotland
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Management of Peutz-Jeghers Syndrome in Children and Adolescents: A Position Paper From the ESPGHAN Polyposis Working Group. J Pediatr Gastroenterol Nutr 2019; 68:442-452. [PMID: 30585892 DOI: 10.1097/mpg.0000000000002248] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Peutz-Jeghers syndrome (PJS) is a well-described inherited syndrome, characterized by the development of gastrointestinal polyps, and characteristic mucocutaneous freckling. Development of small bowel intestinal polyps may lead to intussusception in children may require emergency laparotomy with potential loss of bowel. Gastrointestinal polyps may lead to bleeding and anemia. This European Society for Paediatric Gastroenterology Hepatology and Nutrition position paper provides a guide for diagnosis, assessment, and management of PJS in children and adolescents and guidance on avoiding complications from PJS or from the endoscopic procedures performed on these patients.This is the first position paper regarding PJS published by European Society for Paediatric Gastroenterology Hepatology and Nutrition. Literature from PubMed, Medline, and Embase was reviewed and in the absence of evidence, recommendations reflect the opinion of pediatric and adult experts involved in the care of polyposis syndromes. Because many of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, some of the recommendations are based on expert opinion. This position paper will be helpful in the appropriate management and timing of procedures in children and adolescents with PJS.
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15
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Xavier S, Monteiro S, Magalhães J, Rosa B, Moreira MJ, Cotter J. Capsule endoscopy with PillCamSB2 versus PillCamSB3: has the improvement in technology resulted in a step forward? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:155-159. [PMID: 29278000 DOI: 10.17235/reed.2017.5071/2017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To compare the findings and completion rate of PillCam® SB2 and SB3. METHODS This was a retrospective single-center study that included 357 consecutive small bowel capsule endoscopies (SBCE), 173 SB2 and 184 SB3. The data collected included age, gender, capsule type (PillCam® SB2 or SB3), quality of bowel preparation, completion of the examination, gastric and small bowel transit time, small bowel findings, findings in segments other than the small bowel and the detection of specific anatomical markers, such as the Z line and papilla. RESULTS The mean age of the patients was 48 years and 66.9% were female. The two main indications were suspicion/staging of inflammatory bowel disease (IBD) and obscure gastrointestinal bleeding (OGIB) (43.7% and 40.3%, respectively). Endoscopic findings were reported in 76.2% of examinations and 53.5% were relevant findings. No significant differences were found between SB2 and SB3 with regard to completion rate (93.6% vs 96.2%, p = 0.27), overall endoscopic findings (73.4% vs 78.8%, p = 0.23), relevant findings (54.3% vs 52.7%, p = 0.76), first tertile findings (43.9% vs 48.9%, p = 0.35), extra-SB findings (23.7% vs 17.3%, p = 0.14), Z line and papilla detection rate (35.9% vs 35.7%, p = 0.97 and 27.1% vs 32.6%, p = 0.32, respectively). With regard to the patient subgroups with suspicion/staging of IBD, significant differences were found in relation to the detection of villous edema and the 3rd tertile findings, thus favoring SB3 (26.3% vs 43.8%, p = 0.02 and 47.4% vs 66.3%, p = 0.02, respectively). Mucosal atrophy was significantly more frequently diagnosed with the PillCam® SB3 in patients with anemia/OGIB (0% vs 8%, p = 0.03). CONCLUSIONS Overall, PillCam® SB3 did not improve the diagnostic yield compared to SB2, although it improved the detection of villous atrophy and segmental edema.
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Affiliation(s)
- Sofia Xavier
- Gastroenterology, Hospital da Senhora da Oliveira, Portugal
| | | | | | | | | | - José Cotter
- Gastroenterology, Hospital da Senhora da Oliveira, Portugal
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16
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Kim SH, Yang DH, Kim JS. Current Status of Interpretation of Small Bowel Capsule Endoscopy. Clin Endosc 2018; 51:329-333. [PMID: 30078306 PMCID: PMC6078920 DOI: 10.5946/ce.2018.095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 07/18/2018] [Indexed: 02/06/2023] Open
Abstract
Capsule endoscopy (CE) has revolutionized direct small bowel imaging and is widely used in clinical practice. Remote visualization of bowel images enables painless, well-tolerated endoscopic examinations. Small bowel CE has a high diagnostic yield and the ability to examine the entire small bowel. The diagnostic yield of CE relies on lesion detection and interpretation. In this review, issues related to lesion detection and interpretation of CE have been addressed, and the current status of automated reading software development has been reviewed. Clinical significance of an external real-time image viewer has also been described.
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Affiliation(s)
- Su Hwan Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Su Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Uchida G, Hirooka Y, Nakamura M, Watanabe O, Yamamura T, Matsushita M, Suhara H, Ishikawa T, Furukawa K, Funasaka K, Ohno E, Kawashima H, Miyahara R, Goto H. Nomogram-based prediction of rebleeding in small bowel bleeding patients: the 'PRSBB' score. Sci Rep 2018; 8:6378. [PMID: 29686230 PMCID: PMC5913298 DOI: 10.1038/s41598-018-24868-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/22/2018] [Indexed: 02/08/2023] Open
Abstract
Small bowel capsule endoscopy (SBCE) and balloon-assisted endoscopy (BAE) have revolutionized the diagnosis and treatment of small bowel bleeding (SBB), allowing access to the small bowel and identification of specific bleeding lesions. However, some patients experience rebleeding after small bowel investigation, and there are no definitive algorithms for determining the most appropriate follow-up strategy in SBB patients. We developed and validated a nomogram that can predict rebleeding risk and be used to develop a risk-stratified follow-up strategy in SBB patients. A retrospective study was performed using data from 401 SBB patients who underwent SBCE at Nagoya University Hospital. We developed and internally validated a predictive model for rebleeding in the form of a nomogram using Cox regression models and a bootstrap resampling procedure. Optimal risk factors were selected according to the least absolute shrinkage and selection operator (LASSO). The LASSO method identified 8 independent predictors of rebleeding that could be assessed to obtain a ‘predicting rebleeding in SBB’, or ‘PRSBB’ score: age, sex, SBB type, transfusion requirement, cardiovascular disease, liver cirrhosis, SBCE findings, and treatment. The c-statistic for the predictive model was 0.681. In conclusion, our PRSBB score can help clinicians devise appropriate follow-up plans.
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Affiliation(s)
- Genta Uchida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Osamu Watanabe
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Masanobu Matsushita
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Suhara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Kohei Funasaka
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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18
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Development and validation of a new scoring system to determine the necessity of small-bowel endoscopy in obscure gastrointestinal bleeding. Dig Liver Dis 2017; 49:1218-1224. [PMID: 28958410 DOI: 10.1016/j.dld.2017.08.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Small bowel capsule endoscopy (SBCE) is the recommended first-line procedure for obscure gastrointestinal bleeding (OGIB). However, a method for predicting the necessity of subsequent double-balloon endoscopy (DBE) has not been established. AIMS We aimed to develop a new scoring system that predicts the necessity of DBE in OGIB. METHODS A retrospective study was performed in 330 patients who underwent SBCE for OGIB at Nagoya University Hospital. The enrolled patients were randomly assigned to either a development or a validation dataset. The former was used to construct a prediction scoring system to assess the necessity of DBE using independent predictors selected by logistic regression. The diagnostic yield of the prediction model was assessed using the validation dataset. RESULTS Multivariate logistic regression analysis of the development dataset identified OGIB type, blood transfusion, and SBCE findings as independent predictors of the necessity of DBE. A prediction score gave an area under the receiver operating characteristics curve of 0.77. The sensitivity, specificity, positive predictive value, and negative predictive value at a cutoff ≥2.5 points were 72.5%, 74.6%, 72.6%, and 74.5%, respectively. CONCLUSION Our scoring system may aid clinicians in deciding when to recommend DBE for patients with OGIB.
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19
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Becq A, Rahmi G, Perrod G, Cellier C. Hemorrhagic angiodysplasia of the digestive tract: pathogenesis, diagnosis, and management. Gastrointest Endosc 2017; 86:792-806. [PMID: 28554655 DOI: 10.1016/j.gie.2017.05.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Aymeric Becq
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Gabriel Rahmi
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Guillaume Perrod
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
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20
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Johnston CA, Yung DE, Joshi A, Plevris JN, Koulaouzidis A. Small bowel malignancy in patients undergoing capsule endoscopy at a tertiary care academic center: Case series and review of the literature. Endosc Int Open 2017; 5:E463-E470. [PMID: 28573179 PMCID: PMC5451279 DOI: 10.1055/s-0043-106186] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/02/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Small bowel cancer is rare, accounting for < 5 % of all gastrointestinal neoplasms. Capsule endoscopy has become the procedure of choice for non-invasive diagnosis of small bowel diseases. Data on capsule endoscopy diagnosis of small bowel cancer are limited. The objective of the study was to determine the frequency, indications and diagnostic work-up of patients with small bowel malignancy found by capsule endoscopy at a Scottish tertiary center. PATIENTS AND METHODS In this retrospective study, records all patients who underwent small bowel capsule endoscopy at our center over a 10-year period were reviewed for possible malignancy. Further data were gathered on preceding and subsequent investigations, management and outcome of these patients. RESULTS From 1949 studies, small bowel malignancies were diagnosed in only 7 patients (0.36 %; 2F/5M; median age 50, range 34 - 67). The main indication was iron-deficiency anemia (n = 5). Prior to capsule endoscopy, 6 of 7 patients had bidirectional endoscopies and one had gastroscopy. All prior investigations were normal or nondiagnostic. Two of 7 experienced capsule retention. Five of 7 underwent surgery. Four patients died, giving a 5-year survival rate of 42.9 %. CONCLUSION Small bowel malignancies diagnosed by capsule endoscopy are rare, and the median age of 50 indicates they are more common in relatively younger patients. Capsule endoscopy is effective at diagnosing a rare malignancy when other imaging modalities have failed.
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Affiliation(s)
- Connor A Johnston
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Diana E Yung
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alka Joshi
- Ninewells Hospital and Medical School, Dundee, UK
| | - John N Plevris
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
- Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, UK
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Small-bowel Surveillance in Patients With Peutz-Jeghers Syndrome: Comparing Magnetic Resonance Enteroclysis and Double Balloon Enteroscopy. J Clin Gastroenterol 2017; 51:e27-e33. [PMID: 27404294 DOI: 10.1097/mcg.0000000000000592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Small-bowel surveillance with polypectomy of polyps ≥15 mm prevents complications in patients with Peutz-Jeghers syndrome (PJS). We aimed to compare magnetic resonance enteroclysis (MRE) and double balloon enteroscopy (DBE) for diagnostic yield of these polyps and for patient preference. MATERIALS AND METHODS PJS patients prospectively underwent MRE followed by proximal DBE within 20 weeks. Endoscopists were blinded to the MRE results. We compared number of polyps ≥15 mm detected by MRE and DBE. Patients' perceptions of both procedures were assessed using questionnaires. RESULTS Fifteen PJS patients (67% males, median age 47 y) underwent both MRE and DBE. Polyps ≥15 mm were identified by MRE and/or DBE in 12/15 (80%) patients. There was no significant difference in the detection of polyps ≥15 mm (38 by MRE vs. 50 by DBE, P=0.37). Sensitivity for these polyps was 62% (38/61) for MRE and 82% (50/61) for DBE. Patients' perceived shame and burden did not differ significantly between MRE and DBE. Patients reported significantly more pain during preparation for MRE than for DBE (moderate vs. no pain, P=0.02), although perceived pain during the procedures was comparable (both mild, P=0.89). For future small-bowel surveillance 10/13 (77%) patients preferred DBE over MRE (P=0.09). CONCLUSIONS Our results suggest that MRE and DBE have a comparable diagnostic yield of polyps ≥15 mm. However, DBE allows for direct intervention and was preferred over MRE by most patients in this series. Larger cohorts of PJS patients are needed to fully evaluate the diagnostic yield of DBE compared with other modalities.
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Bosch X, Montori E, Guerra-García M, Costa-Rodríguez J, Quintanilla MH, Tolosa-Chapasian PE, Moreno P, Guasch N, López-Soto A. A comprehensive evaluation of the gastrointestinal tract in iron-deficiency anemia with predefined hemoglobin below 9mg/dL: A prospective cohort study. Dig Liver Dis 2017; 49:417-426. [PMID: 28065528 DOI: 10.1016/j.dld.2016.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 12/06/2016] [Accepted: 12/09/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anemia is defined as hemoglobin below the cutoff of normal in studies examining the gastrointestinal (GI) tract in iron-deficiency anemia (IDA). Although the risk of GI cancer (GIC) increases as hemoglobin decreases, guidelines do not usually recommend hemoglobin thresholds for IDA investigation. METHODS To elucidate whether underlying GI disorders explain the different hemoglobin values and clinical outcomes observed initially in IDA patients referred for GI workup, we prospectively investigated the diagnostic yield of a thorough GI examination in consecutive IDA adults with predefined hemoglobin <9g/dL and no extraintestinal bleeding. RESULTS 4552 patients were enrolled over 10 years. 96% of 4038 GI lesions were consistent with occult bleeding disorders and 4% with non-bleeding disorders. Predominant bleeding disorders included upper GI ulcerative/erosive lesions (51%), GIC (15%), and angiodysplasias (12%). Diffuse angiodysplasias (45% of angiodysplasias) and GIC showed the lowest hemoglobin values (6.3 [1.5] and 6.4 [1.3]g/dL, respectively). While the spread (diffuse vs. localized) and number (<3 vs. ≥3) of angiodysplasias correlated with the degree of anemia, hemoglobin values were lower in GIC with vs. without ulcerated/friable lesions (6.0 [1.1] vs. 7.0 [1.2]g/dL, P<0.001). CONCLUSION Not only GIC but also diffuse angiodysplasias caused the most severe anemia in IDA with predefined hemoglobin values <9g/dL.
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Affiliation(s)
- Xavier Bosch
- Quick Diagnosis Unit, Adult Day Care Center, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Department of Internal Medicine, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Elisabet Montori
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital Plató, Barcelona, Spain
| | - Mar Guerra-García
- Quick Diagnosis Unit, Adult Day Care Center, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | | | | | - Pedro Moreno
- Department of Internal Medicine, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Neus Guasch
- Quick Diagnosis Unit, Adult Day Care Center, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Alfons López-Soto
- Department of Internal Medicine, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Bass LM, Kim S, Superina R, Mohammad S. Jejunal varices diagnosed by capsule endoscopy in patients with post-liver transplant portal hypertension. Pediatr Transplant 2017; 21. [PMID: 27762481 DOI: 10.1111/petr.12818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 12/11/2022]
Abstract
Portal hypertension secondary to portal vein obstruction following liver transplant occurs in 5%-10% of children. Jejunal varices are uncommon in this group. We present a case series of children with significant GI blood loss, negative upper endoscopy, and jejunal varices detected by CE. Case series of patients who had CE for chronic GI blood loss following liver transplantation. Three patients who had their initial transplants at a median age of 7 months were identified at our institution presenting at a median age of 8 years (range 7-16 years) with a median Hgb of 2.8 g/dL (range 1.8-6.8 g/dL). Upper endoscopy was negative for significant esophageal varices, gastric varices, and bleeding portal gastropathy in all three children. All three patients had significant jejunal varices noted on CE in mid-jejunum. Jejunal varices were described as large prominent bluish vessels underneath visualized mucosa, one with evidence of recent bleeding. The results led to venoplasty of the portal vein in two patients and a decompressive shunt in one patient with resolution of GI bleed and anemia. CE is useful to diagnose intestinal varices in children with portal hypertension and GI bleeding following liver transplant.
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Affiliation(s)
- Lee M Bass
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stanley Kim
- Department of Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Riccardo Superina
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Saeed Mohammad
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Clinical outcomes of negative small-bowel capsule endoscopy for small-bowel bleeding: a systematic review and meta-analysis. Gastrointest Endosc 2017; 85:305-317.e2. [PMID: 27594338 DOI: 10.1016/j.gie.2016.08.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/23/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Small-bowel bleeding is the primary indication for capsule endoscopy (CE). Many experts advocate a "watch-and-wait" policy in negative CE. This meta-analysis examines the odds of rebleeding after negative index CE and the impact on long-term follow-up. METHODS A comprehensive literature search identified articles examining the rebleeding rate after negative CE. Demographic and clinical information with emphasis on outcomes was retrieved, pooled, and analyzed. Heterogeneity among studies was assessed using the I2 statistic. A random effects model was used as the pooling method because of high heterogeneity. Risk of bias was assessed using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. The primary outcome evaluated was the pooled odds ratios (ORs) for rebleeding after a negative CE for obscure GI bleeding (OGIB). RESULTS Twenty-six studies with 3657 patients were included. The pooled rate of rebleeding after negative CE was .19 (95% CI, .14-.25; P < .0001). The pooled OR of rebleeding was .59 (95% CI, .37-.95; P < .001). The effect was more pronounced in studies with a short follow-up (OR, .47; 95% CI, .24-.94; P < .001). There was no statistically significant difference in rebleeding after CE for occult and overt OGIB. Prospective studies showed a lower OR of rebleeding of .24 (95% CI, .08-.73; P = .01). Most studies were high quality. CONCLUSIONS Our analysis shows that negative CE provides adequate evidence of a subsequently low risk of rebleeding. Such patients can therefore be safely managed with watchful waiting. However, patients who rebleed after 2 years may need to be investigated for a new source of blood loss.
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Rondonotti E, Koulaouzidis A, Yung DE, Reddy SN, Georgiou J, Pennazio M. Neoplastic Diseases of the Small Bowel. Gastrointest Endosc Clin N Am 2017; 27:93-112. [PMID: 27908521 DOI: 10.1016/j.giec.2016.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The incidence of small bowel tumors is increasing over time. Until recently, their diagnosis was delayed and it was often reached only at the time of surgery. New diagnostic tools, such as capsule endoscopy, device-assisted enteroscopy, and dedicated small bowel cross-sectional imaging techniques, have been introduced recently in clinical practice. The combination of these tools allows medical practitioners to detect small bowel tumors at an early stage and to reach a definite diagnosis before surgery, thus enabling minimally invasive treatments.
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Affiliation(s)
| | - Anastasios Koulaouzidis
- Centre for Liver & Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Diana E Yung
- Centre for Liver & Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Surekha N Reddy
- Department of Radiology, Western General Hospital, Crewe Road South, 51 Little France Crescent, Edinburgh EH3 9JD, UK
| | - Julius Georgiou
- Department of Electrical and Computer Engineering, University of Cyprus, Cyprus 1 University Avenue, Aglantzia 2109, Cyprus
| | - Marco Pennazio
- Division of Gastroenterology U, San Giovanni AS University-Teaching Hospital, Via Cavour 31, Torino 10123, Italy
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Zhang M, Zhang T, Hong L, Wu Q, Lin Y, Xie M, Fan R, Wang Z, Zhou J, Zhong J. Comparison of patients' tolerance between computed tomography enterography and double-balloon enteroscopy. Patient Prefer Adherence 2017; 11:1755-1766. [PMID: 29081651 PMCID: PMC5652905 DOI: 10.2147/ppa.s145562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Computed tomography enterography (CTE) and double-balloon enteroscopy (DBE) are widely used in diagnosis of small bowel diseases. Both of these examinations bring discomfort to patients. The aim of this study was to compare patients' tolerance and preference between CTE and DBE. METHODS From August 1, 2014 to December 31, 2016, patients with suspected or known small bowel diseases who underwent both CTE and DBE were prospectively enrolled in our study. They were asked to fill out a questionnaire evaluating discomfort of the procedure after each examination. RESULTS One hundred and seven patients completed our study. Abdominal distension, painfulness, tenesmus, general discomfort, prolonged duration, difficulty in completing the test, and discomfort after the examination were significantly lower with CTE than with DBE (P<0.001, respectively). Mannitol intake (47.7%), bowel preparation (31.9%), and radiation exposure (15.0%) were regarded as the three most intolerable burdens in CTE. Painfulness (38.3%), bowel preparation (26.2%), and invasiveness (16.8%) were considered as the three most unacceptable parts of DBE. More patients (61.7%) preferred to repeat CTE rather than DBE (P<0.001). CONCLUSION Compared to DBE, CTE was a more tolerable and less burdensome examination and enjoyed higher preference by most patients.
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Affiliation(s)
- Maochen Zhang
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Tianyu Zhang
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Liwen Hong
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Qiangqiang Wu
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Yun Lin
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Mengfan Xie
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Rong Fan
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Zhengting Wang
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
| | - Jie Zhou
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
- Correspondence: Jie Zhong; Jie Zhou, Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, 197 Ruijiner Road, Shanghai 200025, People’s Republic of China, Tel +86 21 6437 0045 ext 600907, Email ;
| | - Jie Zhong
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People’s Republic of China
- Correspondence: Jie Zhong; Jie Zhou, Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, 197 Ruijiner Road, Shanghai 200025, People’s Republic of China, Tel +86 21 6437 0045 ext 600907, Email ;
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Pasha SF, Leighton JA. Detection of suspected small bowel bleeding: challenges and controversies. Expert Rev Gastroenterol Hepatol 2016; 10:1235-1244. [PMID: 27366927 DOI: 10.1080/17474124.2016.1207525] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Detection of small bowel (SB) bleeding remains a challenge to gastroenterologists, with a dearth of standardized recommendations regarding evaluation and management. Areas covered: A recursive literature search was performed using PubMed, Cochrane and Medline databases for original and review articles on SB and obscure gastrointestinal bleeding (OGIB). Based upon the available literature, this review outlines the main challenges and controversies, and provides a practical and cost-effective approach towards SB bleeding. Expert commentary: SB bleeding is suspected in patients with persistent or recurrent bleeding after negative bidirectional endoscopy, and unexplained iron deficiency anemia. Selection of test(s) should be individualized based upon patient presentation and suspicion for type of underlying lesion. Endoscopic or radiologic evaluation and treatment is the mainstay in the majority of patients, while pharmacologic agents may have a role in patients with refractory bleeding, and those unable to undergo evaluation.
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Affiliation(s)
- Shabana F Pasha
- a Division of Gastroenterology and Hepatology , Mayo Clinic Arizona , Scottsdale , AZ , USA
| | - Jonathan A Leighton
- a Division of Gastroenterology and Hepatology , Mayo Clinic Arizona , Scottsdale , AZ , USA
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McAlindon ME, Ching HL, Yung D, Sidhu R, Koulaouzidis A. Capsule endoscopy of the small bowel. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:369. [PMID: 27826572 DOI: 10.21037/atm.2016.09.18] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Capsule endoscopy (CE) is a first line small bowel investigative modality which provides more sensitive mucosal imaging than comparators. It is a non-invasive, non-irradiating tool well tolerated by patients. The risk of retention of the capsule can be minimised by ensuring luminal patency using the Agile patency device. Research continues into how to minimise missed pathology and variability in the identification of pathology or interpretation of images. The consensus is that bowel preparation using laxatives improves visibility and diagnostic yield. Research includes the development of image recognition software, both to eliminate sequentially identical images to improve viewing speed and to select or enhance images likely to represent pathology. However, careful reading by experienced capsule endoscopists remains the benchmark. This should be performed at a speed comfortable to the viewer, probably at a maximum of 15 frames per second. Some prior experience of endoscopy appears to be helpful for novice capsule endoscopists and formal training on a hands-on training course seems to improve pathology recognition, for novices and for those with CE experience.
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Affiliation(s)
- Mark E McAlindon
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Hey-Long Ching
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Diana Yung
- Endoscopy Unit, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Reena Sidhu
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
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29
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Rossi RE, Conte D, Elli L, Branchi F, Massironi S. Endoscopic techniques to detect small-bowel neuroendocrine tumors: A literature review. United European Gastroenterol J 2016; 5:5-12. [PMID: 28405316 DOI: 10.1177/2050640616658220] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 06/12/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The diagnosis of small-bowel neuroendocrine tumors (SbNETs) has improved with the advent of video capsule endoscopy (CE) and double-balloon enteroscopy (DBE). The data describing the efficacy of CE/DBE in the detection of SbNETs are scanty. AIM The aim of this article is to review the current evidence on the role of DBE and CE in the diagnosis of SbNETs. MATERIAL AND METHODS A bibliographical search was performed in PubMed using the following keywords: "neuroendocrine tumors and enteroscopy/and capsule endoscopy" and "small bowel neuroendocrine tumors." RESULTS CE and DBE can be complementary and show a similar diagnostic yield. The number of false-negative results has not been established yet because of the "work-up bias" observed in the majority of the studies. CONCLUSIONS DBE and CE appear to be both safe and effective procedures useful in the diagnosis of SbNETs. Further studies are required to clarify their potential complications and relationship with other techniques, particularly nuclear imaging.
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Affiliation(s)
- Roberta Elisa Rossi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Italy
| | - Luca Elli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy; Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy
| | - Federica Branchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy; Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy
| | - Sara Massironi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy
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30
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Kim JH, Moon W. Optimal Diagnostic Approaches for Patients with Suspected Small Bowel Disease. Clin Endosc 2016; 49:364-9. [PMID: 27334413 PMCID: PMC4977738 DOI: 10.5946/ce.2016.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 06/02/2016] [Indexed: 12/16/2022] Open
Abstract
While the domain of gastrointestinal endoscopy has made great strides over the last several decades, endoscopic assessment of the small bowel continues to be challenging. Recently, with the development of new technology including video capsule endoscopy, device-assisted enteroscopy, and computed tomography/magnetic resonance enterography, a more thorough investigation of the small bowel is possible. In this article, we review the systematic approach for patients with suspected small bowel disease based on these advanced endoscopic and imaging systems.
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Affiliation(s)
- Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Abstract
CT enterography is a first-line test at many institutions to investigate potential small bowel disorders. While numerous articles have focused on the ability of CT enterography to diagnose and stage Crohn's disease, small bowel neoplasia, and malabsorptive or vascular disorders, this article reviews CT enterography limitations, technical and interpretive pitfalls, image review tactics, and complementary radiologic and endoscopic examinations to improve diagnostic accuracy. CT enterography limitations include its inability to demonstrate isolated mucosal abnormalities such as aphthous ulcers and its use of ionizing radiation. The most common technical pitfall of CT enterography is inadequate small bowel distention resulting from inadequate ingestion, gastric retention, or rapid small bowel transit of a large volume of neutral enteric contrast material. Additionally, segments of jejunum are frequently collapsed. Interpretive pitfalls commonly result from peristaltic contractions, transient intussusception and opaque intraluminal debris. Opaque debris is especially problematic during multiphasic CT enterography performed to identify potential small bowel sources of obscure gastrointestinal bleeding. False-negative examinations may result from inadequate radiation dose. Examinations complementary to CT enterography include small bowel follow through, enteroclysis, CT enteroclysis, MR enterography, MR enteroclysis, capsule endoscopy, and balloon-assisted endoscopy. Properly performed and accurately interpreted CT enterography contributes to the diagnosis and management of small bowel disease by itself and as a complement to other radiologic and optical small bowel imaging examinations.
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Monteiro S, de Castro FD, Carvalho PB, Moreira MJ, Rosa B, Cotter J. PillCam ® SB3 capsule: Does the increased frame rate eliminate the risk of missing lesions? World J Gastroenterol 2016; 22:3066-3068. [PMID: 26973404 PMCID: PMC4779931 DOI: 10.3748/wjg.v22.i10.3066] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/02/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
Since its emergence in 2000, small bowel capsule endoscopy (SBCE) has assumed a pivotal role as an investigation method for small bowel diseases. The PillCam® SB2-ex offers 12 h of battery time, 4 more than the previous version (SB2). Rahman et al recently found that the PillCam® SB2-ex has a significantly increased completion rate, although without higher diagnostic yield, compared with the SB2. We would like to discuss these somewhat surprising results and the new potentialities of the PillCam® SB3 regarding the diagnostic yield of small bowel studies. PillCam® SB3 offers improved image resolution and faster adaptable frame rate over previous versions of SBCE. We recently compared the major duodenal papilla detection rate obtained with PillCam® SB3 and SB2 as a surrogate indicator of diagnostic yield in the proximal small bowel. The PillCam® SB3 had a significantly higher major duodenal papilla detection rate than the PillCam® SB2 (42.7% vs 24%, P = 0.015). Thus, the most recent version of the PillCam® capsule, SB3, may increase diagnostic yield, particularly in the proximal segments of the small bowel.
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Sulbaran M, de Moura E, Bernardo W, Morais C, Oliveira J, Bustamante-Lopez L, Sakai P, Mönkemüller K, Safatle-Ribeiro A. Overtube-assisted enteroscopy and capsule endoscopy for the diagnosis of small-bowel polyps and tumors: a systematic review and meta-analysis. Endosc Int Open 2016; 4:E151-63. [PMID: 26878042 PMCID: PMC4751017 DOI: 10.1055/s-0041-108261] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 10/19/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Several studies have evaluated the utility of double-balloon enteroscopy (DBE) and capsule endoscopy (CE) for patients with small-bowel disease showing inconsistent results. The aim of this study was to determine the sensitivity and specificity of overtube-assisted enteroscopy (OAE) as well as the diagnostic concordance between OAE and CE for small-bowel polyps and tumors. PATIENTS AND METHODS We conducted a systematic review and meta-analysis of studies in which the results of OAE were compared with the results of CE for the evaluation of small-bowel polyps and tumors. When data for surgically resected lesions were available, the histopathological results of OAE and surgical specimens were compared. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the diagnosis of small-bowel polyps and tumors were analyzed. Secondarily, the rates of diagnostic concordance and discordance between OAE and CE were calculated. RESULTS There were 15 full-length studies with a total of 821 patients that met the inclusion criteria. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were as follows: 0.89 (95 % confidence interval [CI] 0.84 - 0.93), with heterogeneity χ(2) = 41.23 (P = 0.0002) and inconsistency (I (2)) = 66.0 %; 0.97 (95 %CI 0.95 - 0.98), with heterogeneity χ(2) = 45.27 (P = 0.07) and inconsistency (I (2)) = 69.1 %; 16.61 (95 %CI 3.74 - 73.82), with heterogeneity Cochrane's Q = 225.19 (P < 0.01) and inconsistency (I (2)) = 93.8 %; and 0.14 (95 %CI 0.05 - 0.35), with heterogeneity Cochrane's Q = 81.01 (P < .01) and inconsistency (I (2)) = 82.7 %, respectively. A summary receiver operating characteristic curve (SROC) curve was constructed, and the area under the curve (AUC) was 0.97. CONCLUSION OAE is an accurate test for the detection of small-bowel polyps and tumors. OAE and CE have a high diagnostic concordance rate for small-bowel polyps and tumors. This study was registered in the PROSPERO international database (www.crd.york.ac.uk/prospero/) with the study number CRD42015016000.
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Affiliation(s)
- Marianny Sulbaran
- Gastrointestinal Endoscopy Service. Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Corresponding author Marianny Sulbaran, MD Rua Jose Antonio Coelho 207, Apartment 13 04011060 Sao PauloBrazil(5511) 948526841+55-11-31494790
| | - Eduardo de Moura
- Gastrointestinal Endoscopy Service. Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Wanderley Bernardo
- Gastrointestinal Endoscopy Service. Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Cintia Morais
- Gastrointestinal Endoscopy Service. Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Joel Oliveira
- Gastrointestinal Endoscopy Service. Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Leonardo Bustamante-Lopez
- Surgical Division, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Paulo Sakai
- Gastrointestinal Endoscopy Service. Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Klaus Mönkemüller
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, UAB School of Medicine, Birmingham, Alabama, USA
| | - Adriana Safatle-Ribeiro
- Gastrointestinal Endoscopy Service. Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
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Boal Carvalho P, Cotter J. Contrast-Enhanced Cross Sectional Imaging and Capsule Endoscopy: New Perspectives for a Whole Picture of the Small Bowel. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:28-35. [PMID: 28868427 PMCID: PMC5580122 DOI: 10.1016/j.jpge.2015.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/09/2015] [Indexed: 11/22/2022]
Abstract
Small bowel evaluation is a challenging task and has been revolutionized by high-quality contrasted sectional imaging (CT enterography - CTE) and magnetic resonance enterography (MRE) as well as by small bowel capsule endoscopy (SBCE). The decision of which technique to employ during the investigation of small bowel diseases is not always simple or straightforward. Moreover, contraindications may preclude the use of these techniques in some patients, and although they are noninvasive procedures, may present with various complications. SBCE plays a crucial role in the investigation of both obscure gastrointestinal bleeding and Crohn's disease, but it is also useful for surveillance of patients with Peutz-Jeghers syndrome, while CTE is very accurate in small bowel tumours and in established Crohn's Disease, and its use in patients presenting with gastrointestinal bleeding is increasing. MRE, an expensive and not widely available technique, is essential for the study of patients with Crohn's Disease, and presents an attractive alternative to SBCE in Peutz-Jeghers syndrome surveillance. These diagnostic modalities are often not competitive but synergistic techniques. Knowing their characteristics, strengths and limitations, indications, contraindications and potential complications, as well as the adaptation to local availability and expertise, is essential to better select which procedures to perform in each patient, both safely and effectively, in order to optimize management and improve patient outcomes.
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Affiliation(s)
- Pedro Boal Carvalho
- Gastroenterology Department, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - José Cotter
- Gastroenterology Department, Centro Hospitalar do Alto Ave, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães, Portugal
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Long-Term Outcomes in Patients with Overt Obscure Gastrointestinal Bleeding After Negative Double-Balloon Endoscopy. Dig Dis Sci 2015; 60:3691-6. [PMID: 26173504 DOI: 10.1007/s10620-015-3792-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 06/29/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The long-term outcomes of patients after negative double-balloon endoscopy (DBE) for obscure gastrointestinal (GI) bleeding remain unclear. AIM The aim of this study was to assess the long-term outcomes of patients with negative DBE and clarify the effect of repeat endoscopic work-up. METHODS A total of 42 patients with a negative DBE for overt obscure GI bleeding were enrolled, and their clinical data were retrospectively reviewed. The mean (± standard deviation) follow-up period is 5.4 (± 2.8) years. The outcome measurement was overt rebleeding witnessed by the patient after negative DBE. At the time of rebleeding, further endoscopic work-up and specific treatment were performed. RESULTS Rebleeding occurred in 16 of 42 patients (38%). At the time of rebleeding, further investigations were made in 14 of 16 patients (88%), and the bleeding source was identified in 10 of 14 patients (71%). These 10 patients received specific treatment (endoscopic in five, surgical in two, medical in two, and angiographic in one). The bleeding source was in the small intestine in seven of 10 patients (70%). Blood transfusion before DBE and multiple bleeding episodes before DBE were significant predictive factors for rebleeding (odds ratio 5.056, 95% confidence interval 1.158-22.059, p = 0.031 and odds ratio 8.167, 95% confidence interval 1.537-43.392, p = 0.014, respectively). CONCLUSIONS The rebleeding rate after a negative DBE is considerable. Careful long-term follow-up and repeat endoscopic work-up at the time of overt rebleeding are important.
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Haanstra JF, Al-Toma A, Dekker E, Vanhoutvin SALW, Nagengast FM, Mathus-Vliegen EM, van Leerdam ME, de Vos tot Nederveen Cappel WH, Sanduleanu S, Veenendaal RA, Cats A, Vasen HFA, Kleibeuker JH, Koornstra JJ. Prevalence of small-bowel neoplasia in Lynch syndrome assessed by video capsule endoscopy. Gut 2015; 64:1578-83. [PMID: 25209657 DOI: 10.1136/gutjnl-2014-307348] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 08/20/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim was to determine the prevalence of small-bowel neoplasia in asymptomatic patients with Lynch syndrome (LS) by video capsule endoscopy (VCE). DESIGN After obtaining informed consent, asymptomatic proven gene mutation carriers aged 35-70 years were included in this prospective multicentre study in the Netherlands. Patients with previous small-bowel surgery were excluded. After bowel preparation, VCE was performed. The videos were read by two independent investigators. If significant lesions were detected, an endoscopic procedure was subsequently performed to obtain histology and, if possible, remove the lesion. RESULTS In total, 200 patients (mean age 50 years (range 35-69), M/F 88/112), with proven mutations were included. These concerned MLH1 (n = 50), MSH2 (n = 68), MSH6 (n = 76), PMS2 (n = 3) and Epcam (n = 3) mutation carriers. In 95% of the procedures, caecal visualisation was achieved. Small-bowel neoplasia was detected in two patients: one adenocarcinoma (TisN0Mx) and one adenoma, both located in the duodenum. In another patient, a duodenal cancer (T2N0Mx) was diagnosed 7 months after a negative VCE. This was considered a lesion missed by VCE. All three neoplastic lesions were within reach of a conventional gastroduodenoscope. All patients with neoplasia were men, over 50 years of age and without a family history of small-bowel cancer. CONCLUSIONS The prevalence of small-bowel neoplasia in asymptomatic patients with LS was 1.5%. All neoplastic lesions were located in the duodenum and within reach of conventional gastroduodenoscopy. Although VCE has the potential to detect these neoplastic lesions, small-bowel neoplasia may be missed. TRIAL REGISTRATION NUMBER NCT00898768.
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Affiliation(s)
- Jasmijn F Haanstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Abdul Al-Toma
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Steven A L W Vanhoutvin
- Department of Gastroenterology and Hepatology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Amsterdam, The Netherlands
| | - Fokko M Nagengast
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | | | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Amsterdam, The Netherlands Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Silvia Sanduleanu
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roeland A Veenendaal
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemieke Cats
- Department of Gastroenterology and Hepatology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Amsterdam, The Netherlands
| | - Hans F A Vasen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands The Netherlands Foundation for the Detection of Hereditary Tumours, Leiden, The Netherlands
| | - Jan H Kleibeuker
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan J Koornstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol 2015; 110:1265-87; quiz 1288. [PMID: 26303132 DOI: 10.1038/ajg.2015.246] [Citation(s) in RCA: 381] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 06/01/2015] [Indexed: 02/06/2023]
Abstract
Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.
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Igawa A, Oka S, Tanaka S, Kunihara S, Nakano M, Aoyama T, Chayama K. Major predictors and management of small-bowel angioectasia. BMC Gastroenterol 2015; 15:108. [PMID: 26302944 PMCID: PMC4549087 DOI: 10.1186/s12876-015-0337-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/13/2015] [Indexed: 12/15/2022] Open
Abstract
Background Small-bowel angioectasias are frequently diagnosed with capsule endoscopy (CE) or balloon endoscopy however, major predictors have not been defined and the indications for endoscopic treatment have not been standardized. The aim of this study was to evaluate the predictors and management of small-bowel angioectasia. Methods Among patients with obscure gastrointestinal bleeding (OGIB) who underwent both CE and double-balloon endoscopy at our institution, we enrolled 64 patients with small-bowel angioectasia (angioectasia group) and 97 patients without small-bowel angioectasia (non-angioectasia group). The angioectasia group was subdivided into patients with type 1a angioectasia (35 cases) and type 1b angioectasia (29 cases) according to the Yano-Yamamoto classification. Patient characteristics, treatment, and outcomes were evaluated. Results Age (P = 0.001), cardiovascular disease (P = 0.002), and liver cirrhosis (P = 0.003) were identified as significant predictors of small-bowel angioectasia. Multivariate logistic regression analysis identified cardiovascular disease (odds ratio 2.86; 95 % confidence interval, 1.35–6.18) and liver cirrhosis (odds ratio 4.81; 95 % confidence interval, 1.79–14.5) as independent predictors of small-bowel angioectasia. Eleven type 1a cases without oozing were treated conservatively, and 24 type 1a cases with oozing were treated with polidocanol injection (PDI). Re-bleeding occurred in two type 1a cases (6 %). Seventeen type 1b cases were treated with PDI and 12 type 1b cases were treated with PDI combined with argon plasma coagulation (APC) or clipping. Re-bleeding occurred in five type 1b cases (17 %) that resolved after additional endoscopic hemostasis in all cases. There was one adverse event from endoscopic treatment (1.6 %). Conclusions Cardiovascular disease and liver cirrhosis were significant independent major predictors of small-bowel angioectasia. Type 1a angioectasias with oozing are indicated for PDI and type 1b angioectasias are indicated for PDI with APC or clipping.
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Affiliation(s)
- Atsushi Igawa
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
| | - Shiro Oka
- Department of Endoscopy, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Sayoko Kunihara
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
| | - Makoto Nakano
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
| | - Taiki Aoyama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
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Ribeiro I, Pinho R, Rodrigues A, Fernandes C, Silva J, Ponte A, Tente D, Carvalho J. The Importance of Alternative Diagnostic Modalities in the Diagnosis of Small Bowel Tumors After a Negative Capsule Endoscopy. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2015; 22:112-116. [PMID: 28868387 PMCID: PMC5580001 DOI: 10.1016/j.jpge.2015.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 01/31/2015] [Indexed: 02/07/2023]
Abstract
Capsule endoscopy is widely accepted as the preferred diagnostic test in the evaluation of small bowel diseases, especially in the setting of obscure gastrointestinal bleeding. It has revolutionized small bowel examination and has improved the detection of small bowel tumors. However, small bowel tumors are sometimes missed by capsule endoscopy. Furthermore, there are several recent reports comparing capsule endoscopy with other diagnostic modalities, such as double balloon enteroscopy and CT/RM enterography, that challenge the reportedly high negative predictive value of capsule endoscopy in detecting small bowel tumors. We report the case of a patient with overt obscure gastrointestinal bleeding due to a gastrointestinal stromal tumor diagnosed by CT enterography after two negatives capsule endoscopies. This case shows that capsule endoscopy may overlook significant life threatening lesions and highlights the importance of using other diagnostic modalities after a negative capsule endoscopy, especially in patients with a high index of suspicion for small bowel tumoral pathology or persistent/recurrent bleeding.
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Affiliation(s)
- Iolanda Ribeiro
- Gastroenterology and Hepatology Department, Centro Hospitalar de Vila Nova de Gaia /Espinho, Vila Nova de Gaia, Portugal
| | - Rolando Pinho
- Gastroenterology and Hepatology Department, Centro Hospitalar de Vila Nova de Gaia /Espinho, Vila Nova de Gaia, Portugal
| | - Adélia Rodrigues
- Gastroenterology and Hepatology Department, Centro Hospitalar de Vila Nova de Gaia /Espinho, Vila Nova de Gaia, Portugal
| | - Carlos Fernandes
- Gastroenterology and Hepatology Department, Centro Hospitalar de Vila Nova de Gaia /Espinho, Vila Nova de Gaia, Portugal
| | - Joana Silva
- Gastroenterology and Hepatology Department, Centro Hospitalar de Vila Nova de Gaia /Espinho, Vila Nova de Gaia, Portugal
| | - Ana Ponte
- Gastroenterology and Hepatology Department, Centro Hospitalar de Vila Nova de Gaia /Espinho, Vila Nova de Gaia, Portugal
| | - Davide Tente
- Pathology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - João Carvalho
- Gastroenterology and Hepatology Department, Centro Hospitalar de Vila Nova de Gaia /Espinho, Vila Nova de Gaia, Portugal
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Hosoe N, Naganuma M, Ogata H. Current status of capsule endoscopy through a whole digestive tract. Dig Endosc 2015; 27:205-15. [PMID: 25208463 DOI: 10.1111/den.12380] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 09/05/2014] [Indexed: 02/06/2023]
Abstract
More than a decade has passed since small-bowel capsule endoscopy (CE) was first reported. Small-bowel CE is a non-invasive tool that allows visualization of the entire small-intestinal mucosa and facilitates detection of small-intestinal abnormalities. Several studies have shown benefit of small-bowel CE for certain disorders. Because it is non-invasive, CE has been applied to other organs including the esophagus, stomach, and colon. The main indications for esophageal CE (ECE) are screening for gastroesophageal reflux disease/Barrett's esophagus, and esophageal varices. However, the clinical benefit of ECE is unconfirmed. Magnetically guided CE (MGCE) was developed to visualize the gastric mucosa. MGCE is a new concept with room for improvement of capsule navigation and the preparation protocol. Recently, two new small-bowel CE tools were released. First-generation colon CE (CCE-1) has moderate sensitivity and specificity compared with colonoscopy for colorectal neoplasia surveillance. To obtain higher accuracy, a second-generation CCE (CCE-2) was developed with a high sensitivity for detecting clinically relevant polypoid lesions. A possible application of CCE is for inflammatory bowel disease. In the near future, CE may include diagnostic and therapeutic functions such as magnifying endoscopy systems, targeted biopsy forceps, and drug delivery systems.
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Affiliation(s)
- Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo, Japan
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Baltes P, Kurniawan N, Keuchel M. Capsule endoscopy in the evaluation of small bowel tumors and polyps. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2015.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Pinto-Pais T, Pinho R, Rodrigues A, Fernandes C, Ribeiro I, Fraga J, Carvalho J. Emergency single-balloon enteroscopy in overt obscure gastrointestinal bleeding: Efficacy and safety. United European Gastroenterol J 2014; 2:490-6. [PMID: 25452844 DOI: 10.1177/2050640614554850] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 09/16/2014] [Indexed: 01/26/2023] Open
Abstract
UNLABELLED We aimed to evaluate the impact of emergency single-balloon enteroscopy (SBE) on the diagnosis and treatment for active overt obscure gastrointestinal bleeding (OGIB). METHODS SBE procedures for OGIB were retrospectively reviewed and sub-divided according to the bleeding types: active-overt and inactive-overt bleeding. The patient's history, laboratory results, endoscopic findings and therapeutic interventions were registered. Emergency SBE was defined as an endoscopy that was performed for active-overt OGIB, within 24 hours of clinical presentation. RESULTS Between January 2010 and February 2013, 53 SBEs were performed in 43 patients with overt OGIB. Seventeen emergency SBEs were performed in 15 patients with active overt-OGIB procedures (group A), which diagnosed the bleeding source in 14: angiodysplasia (n = 5), ulcers/erosions (n = 3), bleeding tumors (gastrointestinal stromal tumor (GIST), n = 3; neuroendocrine tumor, n = 1), and erosioned polyps (n = 2). Endoscopic treatment was performed in nine patients, with one or multiple hemostatic therapies: argon plasma coagulation (n = 5), epinephrine submucosal injection (n = 5), hemostatic clips (n = 3), and polypectomy (n = 2). Twenty-eight patients with inactive bleeding (group B) were submitted to 36 elective SBEs, which successfully diagnosed 18 cases. The diagnostic yield in group A (93.3%) was significantly higher than in group B (64.3%)-Fisher's exact test, p = 0.038. CONCLUSION This study revealed an important role of emergency SBE in the diagnosis of bleeding etiology in active overt OGIB.
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Affiliation(s)
- Teresa Pinto-Pais
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Gaia, Portugal
| | - Rolando Pinho
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Gaia, Portugal
| | - Adélia Rodrigues
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Gaia, Portugal
| | - Carlos Fernandes
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Gaia, Portugal
| | - Iolanda Ribeiro
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Gaia, Portugal
| | - José Fraga
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Gaia, Portugal
| | - João Carvalho
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Gaia, Portugal
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Baptista V, Marya N, Singh A, Rupawala A, Gondal B, Cave D. Continuing challenges in the diagnosis and management of obscure gastrointestinal bleeding. World J Gastrointest Pathophysiol 2014; 5:523-533. [PMID: 25400996 PMCID: PMC4231517 DOI: 10.4291/wjgp.v5.i4.523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/28/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and management of obscure gastrointestinal bleeding (OGIB) have changed dramatically since the introduction of video capsule endoscopy (VCE) followed by deep enteroscopy and other imaging technologies in the last decade. Significant advances have been made, yet there remains room for improvement in our diagnostic yield and treatment capabilities for recurrent OGIB. In this review, we will summarize the latest technologies for the diagnosis of OGIB, limitations of VCE, technological enhancement in VCE, and different management options for OGIB.
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Fernandez-Urien I, Carretero C, Borobio E, Borda A, Estevez E, Galter S, Gonzalez-Suarez B, Gonzalez B, Lujan M, Martinez JL, Martínez V, Menchén P, Navajas J, Pons V, Prieto C, Valle J. Capsule endoscopy capture rate: Has 4 frames-per-second any impact over 2 frames-per-second? World J Gastroenterol 2014; 20:14472-14478. [PMID: 25339834 PMCID: PMC4202376 DOI: 10.3748/wjg.v20.i39.14472] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 05/20/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the current capsule and a new prototype at 2 and 4 frames-per-second, respectively, in terms of clinical and therapeutic impact.
METHODS: One hundred patients with an indication for capsule endoscopy were included in the study. All procedures were performed with the new device (SB24). After an exhaustive evaluation of the SB24 videos, they were then converted to “SB2-like” videos for their evaluation. Findings, frames per finding, and clinical and therapeutic impact derived from video visualization were analyzed. Kappa index for interobserver agreement and χ2 and Student’s t tests for qualitative/quantitative variables, respectively, were used. Values of P under 0.05 were considered statistically significant.
RESULTS: Eighty-nine out of 100 cases included in the study were ultimately included in the analysis. The SB24 videos detected the anatomical landmarks (Z-line and duodenal papilla) and lesions in more patients than the “SB2-like” videos. On the other hand, the SB24 videos detected more frames per landmark/lesion than the “SB2-like” videos. However, these differences were not statistically significant (P > 0.05). Both clinical and therapeutic impacts were similar between SB24 and “SB2-like” videos (K = 0.954). The time spent by readers was significantly higher for SB24 videos visualization (P < 0.05) than for “SB2-like” videos when all images captured by the capsule were considered. However, these differences become non-significant if we only take into account small bowel images (P > 0.05).
CONCLUSION: More frames-per-second detect more landmarks, lesions, and frames per landmark/lesion, but is time consuming and has a very low impact on clinical and therapeutic management.
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Sethi S, Cohen J, Thaker AM, Garud S, Sawhney MS, Chuttani R, Pleskow DK, Falchuk K, Berzin TM. Prior capsule endoscopy improves the diagnostic and therapeutic yield of single-balloon enteroscopy. Dig Dis Sci 2014; 59:2497-502. [PMID: 24798998 DOI: 10.1007/s10620-014-3178-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 04/19/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Although there is substantial literature addressing double-balloon enteroscopy, evidence is more limited with regard to the clinical utility of single-balloon enteroscopy (SBE) in evaluating and treating small-bowel diseases. We sought to determine the diagnostic and therapeutic yield of SBE in patients with suspected small-bowel disorders, as well as the impact of preceding capsule endoscopy (CE) on these outcomes. METHODS We performed a retrospective analysis of a prospectively collected database at a tertiary-care academic medical center between 2011 and 2013 for all patients referred for SBE. RESULTS A total of 150 patients underwent 170 SBE procedures during the study period. The most frequent indications for SBE included anemia, overt or occult gastrointestinal bleeding, and suspected mass. CE was performed prior to SBE in 113 of 150 patients (75%). The overall diagnostic yield for small-bowel disease by CE was 62%. Therapeutic interventions included hemostasis, polypectomy, and foreign body removal. Total diagnostic and therapeutic yield of SBE was 60 and 28%, respectively. The diagnostic yield of SBE with prior CE was 68 versus 44% for SBE without prior CE (P = 0.002). The therapeutic yield of SBE with prior CE was 35 versus 12% without prior CE (P = 0.001). One endoscopic complication was observed out of 170 procedures, and there were no deaths. CONCLUSIONS SBE appears to be a safe and effective technique for the diagnosis and treatment of small-bowel disease; however, we recommend performing a CE prior to SBE to improve the diagnostic and therapeutic yield of the procedure.
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Affiliation(s)
- Saurabh Sethi
- Division of Gastroenterology, Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
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Utility of 3-dimensional image reconstruction in the diagnosis of small-bowel masses in capsule endoscopy (with video). Gastrointest Endosc 2014; 80:642-651. [PMID: 24998466 DOI: 10.1016/j.gie.2014.04.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 04/28/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND In small-bowel capsule endoscopy (SBCE), differentiating masses (ie, lesions of higher probability for neoplasia) requiring more aggressive intervention from bulges (essentially, false-positive findings) is a challenging task; recently, software that enables 3-dimensional (3D) reconstruction has become available. OBJECTIVE To evaluate whether "coupling" 3D reconstructed video clips with the standard 2-dimensional (s2D) counterparts helps in distinguishing masses from bulges. DESIGN Three expert and 3 novice SBCE readers, blind to others and in a random order, reviewed the s2D video clips and subsequently the s2D clips coupled with their 3D reconstruction (2D+3D). SETTING Multicenter study in 3 community hospitals in Italy and a university hospital in Scotland. PATIENTS Thirty-two deidentified 5-minute video clips, containing mucosal bulging (19) or masses (13). INTERVENTION 3D reconstruction of s2D SBCE video clips. MAIN OUTCOME MEASURE Differentiation of masses from bulges with s2D and 2D+3D video clips, estimated by the area under the receiver operating characteristic curve (AUC); interobserver agreement. RESULTS AUC for experts and novices for s2D video clips was .74 and .5, respectively (P = .0053). AUC for experts and novices with 2D+3D was .70 (compared with s2D: P = .245) and .57 (compared s2D: P = .049), respectively. AUC for experts and novices with 2D+3D was similar (P = .1846). The interobserver agreement was good for both experts and novices with the s2D (k = .71 and .54, respectively) and the 2D+3D video clips (k = .58 in both groups). LIMITATIONS Few, short video clips; fixed angle of 3D reconstruction. CONCLUSIONS The adjunction of a 3D reconstruction to the s2D video reading platform does not improve the performance of expert SBCE readers, although it significantly increases the performance of novices in distinguishing masses from bulging.
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Neumann H, Fry LC, Nägel A, Neurath MF. Wireless capsule endoscopy of the small intestine: a review with future directions. Curr Opin Gastroenterol 2014; 30:463-71. [PMID: 25029549 DOI: 10.1097/mog.0000000000000101] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Here, we review the clinical applications of small bowel capsule endoscopy. Moreover, we provide an outlook on the exceptional future developments of small bowel capsule endoscopy. We discuss clinical algorithms for diagnosis of small bowel diseases. Multiple studies have shown the potential of capsule endoscopy for identification of the bleeding source located in the small bowel and the increased diagnostic yield over radiographic studies. Capsule endoscopy could detect villous atrophy and severe complications in patients with nonresponsive celiac disease. In addition, small bowel capsule endoscopy was proven as a valid tool to diagnose polyps and tumors and Crohn's disease. SUMMARY Major current clinical indications of capsule endoscopy in the small bowel include evaluation of obscure gastrointestinal bleeding, diagnosis and surveillance of small bowel polyps and tumors, celiac disease and Crohn's disease. Recent developments have also passed the way for small bowel capsule endoscopy to become a therapeutic instrument.
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Affiliation(s)
- Helmut Neumann
- aDepartment of Medicine I, University of Erlangen-Nürnberg, Erlangen bLudwig Demling Endoscopic Center of Excellence, University Hospital Erlangen, Erlangen, Germany cDivision of Gastroenterology and Hepatology, Basil Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Matsumura T, Arai M, Saito K, Okimoto K, Saito M, Minemura S, Oyamada A, Maruoka D, Nakagawa T, Watabe H, Katsuno T, Yokosuka O. Predictive factor of re-bleeding after negative capsule endoscopy for obscure gastrointestinal bleeding: over 1-year follow-up study. Dig Endosc 2014; 26:650-8. [PMID: 24628735 DOI: 10.1111/den.12257] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 01/22/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Capsule endoscopy (CE) is now widely accepted as a first-line diagnostic modality for obscure gastrointestinal bleeding (OGIB), with a high diagnostic yield compared to other modalities. However, even after negative CE examination, re-bleeding is often known to occur. The aim of the present study was to identify predictive factors of re-bleeding after negative CE, and to clarify the clinical utility of double-balloon enteroscopy (DBE) after negative CE for OGIB. METHODS Two hundred and sixty patients who underwent CE for OGIB between October 2007 and September 2012 were included, and followed up for at least 1 year after CE examination. Demographic and clinical parameters associated with re-bleeding after negative CE were investigated. RESULTS A total of 154 patients (59.2%) had negative findings. Thirteen of those patients (8.4%) had one or more re-bleeding episodes during the follow-up period. In comparing patients with and without re-bleeding, Cox hazard regression analysis revealed that advanced age was a predictive factor for re-bleeding after negative CE (hazard ratio 1.05 [1.01-1.10], P = 0.03). Subsequent DBE for reasons other than re-bleeding was carried out in 51 patients (33.1%). Mucosal lesions (ulcer or multiple erosions) were subsequently detected in seven patients (13.7%), and endoscopic therapies were carried out in two patients (3.9%). CONCLUSIONS In patients of advanced age, more extensive follow up is needed, even if the CE result is negative. In addition, DBE subsequent to negative CE may be useful to detect lesions that were overlooked on CE.
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Affiliation(s)
- Tomoaki Matsumura
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Tomas C, Soyer P, Dohan A, Dray X, Boudiaf M, Hoeffel C. Update on imaging of Peutz-Jeghers syndrome. World J Gastroenterol 2014; 20:10864-10875. [PMID: 25152588 PMCID: PMC4138465 DOI: 10.3748/wjg.v20.i31.10864] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant disease linked to a mutation of the STK 11 gene and is characterized by the development of benign hamartomatous polyps in the gastrointestinal tract in association with a hyperpigmentation on the lips and oral mucosa. Patients affected by PJS have an increased risk of developing gastrointestinal and extra-digestive cancer. Malignancy most commonly occurs in the small-bowel. Extra-intestinal malignancies are mostly breast cancer and gynecological tumors or, to a lesser extent, pancreatic cancer. These polyps are also at risk of acute gastrointestinal bleeding, intussusception and bowel obstruction. Recent guidelines recommend regular small-bowel surveillance to reduce these risks associated with PJS. Small-bowel surveillance allows for the detection of large polyps and the further referral of selected PJS patients for endoscopic enteroscopy or surgery. Video capsule endoscopy, double balloon pushed enteroscopy, multidetector computed tomography and magnetic resonance enteroclysis or enterography, all of which are relatively new techniques, have an important role in the management of patients suffering from PJS. This review illustrates the pathological, clinical and imaging features of small-bowel abnormalities as well as the role and performance of the most recent imaging modalities for the detection and follow-up of PJS patients.
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Towbin AJ, Sullivan J, Denson LA, Wallihan DB, Podberesky DJ. CT and MR enterography in children and adolescents with inflammatory bowel disease. Radiographics 2014; 33:1843-60. [PMID: 24224581 DOI: 10.1148/rg.337105140] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The term inflammatory bowel disease (IBD) is used to describe multiple idiopathic disorders of the gastrointestinal tract. As many as one-quarter of patients with IBD initially present in childhood or adolescence. Multiple methods can be used to diagnose IBD in this age group, including computed tomographic (CT) enterography, magnetic resonance (MR) enterography, small bowel follow-through examination, ileocolonoscopy, and capsule endoscopy. However, CT enterography and MR enterography have become the imaging modalities of choice due to their exquisite image quality, rapid acquisition time, lack of need for bowel preparation, and ability to help diagnose the extraintestinal complications of IBD. In addition to being radiation free, MR enterography can help evaluate peristalsis, has high contrast resolution, and allows the use of diffusion-weighted imaging. The authors discuss the use of CT enterography and MR enterography in the context of pediatric IBD in terms of advantages and disadvantages, protocol, and imaging findings.
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Affiliation(s)
- Alexander J Towbin
- From the Departments of Radiology (A.J.T., J.S., D.B.W., D.J.P.) and Gastroenterology (L.A.D.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, ML 5031, Cincinnati, OH 45241
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