Video capsule endoscopy in the work-up of abdominal pain

Diagnostic Yield and Clinical Impact of Video Capsule Endoscopy in Patients with Chronic Diarrhea: A Korean Multicenter CAPENTRY Study

Background/Aims

In some cases, chronic diarrhea is unexplained, and small bowel disorders may be one of the causes. The aim of this study was to assess the diagnostic yield and clinical impact of video capsule endoscopy (VCE) in patients with chronic diarrhea.

Methods

We retrospectively analyzed records from October 2002 to August 2013 in the VCE nationwide database registry (n=2,964). Ninety-one patients from 15 medical centers (60 males and 31 females; mean age, 47±19 years) were evaluated for VCE as a result of chronic diarrhea.

Results

The duration of chronic diarrhea was 8.3±14.7 months. The positive diagnostic yield of VCE was 42.9% (39/91). However, 15.4% (14/91) exhibited an inconsistent result, and 41.8% (38/91) were negative. Abnormal findings consistent with chronic diarrhea included erosions/aphthous ulcers (19.8%), ulcers (17.6%), mucosal erythema (3.3%), edema (1.1%), and luminal narrowing (1.1%). The most common diagnoses were functional diarrhea associated with irritable bowel syndrome in 37 patients (40.7%) and Crohn's disease in 18 patients (19.8%). After VCE examination, the diagnosis was changed in 34.1% of the patients (31/91). Hematochezia (odds ratio [OR], 8.802; 95% confidence interval [CI], 2.126 to 36.441) and hypoalbuminemia (OR, 4.811; 95% CI, 1.241 to 18.655) are predictive factors of a positive diagnostic yield.

Conclusions

VCE had a favorable diagnostic yield and clinical impact on the management of patients with chronic diarrhea.

Diagnostic yield and clinical impact of wireless capsule endoscopy in patients with chronic abdominal pain with or without diarrhea: a Greek multicenter study

BACKGROUND

Wireless capsule endoscopy has become the gold standard for the examination of small bowel. However, its role in the evaluation of patients suffering from chronic abdominal pain is not yet clearly defined. We conducted an open-label prospective multi-center study to evaluate the yield and clinical outcome of capsule endoscopy in patients with chronic abdominal pain with/without diarrhea.

METHODS

Seventy-two patients with chronic (>3months) abdominal pain with/without diarrhea in whom the underlying pathology could not be diagnosed by conventional modalities, underwent capsule endoscopy in either of the 6 participating centers. Patients were then followed up for clinical outcomes.

RESULTS

The overall diagnostic yield of capsule endoscopy was 44.4%. More specifically, its diagnostic yield was 21.4% in patients with abdominal pain and negative inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), 66.7% in patients with abdominal pain and positive inflammatory markers, 0% in patients with abdominal pain, diarrhea and negative inflammatory markers, and 90.1% in patients with abdominal pain, diarrhea and positive inflammatory markers. Both univariate and multivariate regression analyses showed that abnormal C-reactive protein and erythrocyte sedimentation rate were significant factors related with positive capsule endoscopy findings.

CONCLUSIONS

Chronic abdominal pain with/without diarrhea should be accompanied by elevated inflammatory markers to be regarded as a valid indication for capsule endoscopy. The yield of capsule endoscopy in such patients is reasonably high and clinical outcomes of patients treated with capsule endoscopy findings as a guide are significant.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Wireless video capsule in pediatric patients with functional abdominal pain

OBJECTIVES

Upper endoscopy (esophagogastroduodenoscopy [EGD]) has a limited role, if any, in the evaluation of functional abdominal pain (FAP). Nevertheless, children with intractable FAP are occasionally referred to EGD to rule out intestinal pathology. We evaluated the role of wireless video capsule endoscopy (VCE) in children referred for EGD with a diagnosis of FAP.

PATIENTS AND METHODS

Ten children older than 10 years of age were prospectively enrolled. Children were first studied with the PillCam SB (VCE; Given Imaging, Yokneam, Israel) followed by standard EGD within 2 weeks. After the completion of the study, a questionnaire of tolerance and content regarding the 2 procedures was completed by the patients.

RESULTS

Physical examinations and laboratory tests were within normal limits in all of the patients. Patients swallowed the endoscopic capsules without difficulty. There were no complications. VCE identified gastritis in 4 patients (confirmed by biopsies), whereas EGD detected erosive gastritis in only 1 of the 4 children. EGD detected no duodenal abnormalities. VCE detected Crohn disease in the small intestine and cecum in 1 patient. VCE was ranked by 8 patients as convenient and as a preferable procedure compared with EGD.

CONCLUSION

The results of this small cohort suggest that in children with FAP, VCE is more sensitive than EGD for detection of macroscopic gastric and small bowel pathologies.

Capsule endoscopy in patients with chronic abdominal pain

BACKGROUND

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

AIM

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

PATIENTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Abdominal pain accompanied by weight loss may increase the diagnostic yield of capsule endoscopy: a Korean multicenter study

OBJECTIVE

Capsule endoscopy (CE) is approved for the evaluation of obscure gastrointestinal (GI) bleeding and its use has increased in the assessment of patients with various small-bowel disorders. The yield of CE for indications of disorders other than GI bleeding is not yet well described. The aim of the present study was to determine in which subgroup of patients with unexplained abdominal pain, CE would be a helpful evaluation tool.

MATERIAL AND METHODS

The results of CE in 110 patients (70 M, 40 F, mean age 50.8+/-14.1 years) with unexplained abdominal pain from 12 tertiary referral centers between September 2002 and September 2004 were retrospectively analyzed.

RESULTS

The visualization of the small bowel to the cecum was successfully carried out in 69.1% of the patients. Nineteen out of the 110 cases revealed positive findings that explained the symptoms of the patient (diagnostic yield=17.3%). Diagnosis included small-bowel stricture (5), Crohn's disease (3), small-bowel tumor (2), radiation-induced enteritis (1), NSAID-induced enteropathy (1), ischemic ileitis (1), diffuse lymphangiectasia (1), and significant erosion or ulceration (5). By univariate logistic regression analysis, the positive findings of CE were significantly associated with weight loss (odds ratio (OR), 11.9; 95% CI [2.0, 70.6]), elevated erythrocyte sedimentation rate (ESR) (>20 mm/h) (OR, 11.5; 95% CI (1.9, 69.5)), elevated C-reactive protein (CRP) (>or=0.4 mg/dL) (OR, 5.0; 95% CI (1.6, 15.9)), and hypoalbuminemia (albumin<3 g/dL) (OR, 23.1; 95% CI (2.4, 223.1)). Using a multivariate analysis, weight loss was found to be a significant risk factor for positive findings of CE (OR, 18.6; 95% CI (1.6, 222.4), p=0.02).

CONCLUSIONS

The results of this study suggest that CE can be helpful in patients suffering from abdominal pain that cannot be explained by established examinations, if the pain is accompanied by weight loss.

Technology Insight: current status of video capsule endoscopy

Video capsule endoscopy (VCE) is the most recent major practical and conceptual development in the field of endoscopy. The video capsule endoscope-a small, pill-sized, passive imaging device-has been demonstrated to be the pre-eminent imaging device for disorders of the small intestine. The initial use for VCE was to detect the origin of obscure gastrointestinal bleeding. Several other indications have now been justified, or are in the process of evaluation. More than 200,000 of these disposable devices have been used worldwide, with an extraordinarily good safety record: indeed, the device has been approved for use in children as young as 10 years of age. In addition, a double-ended capsule has now been approved for the evaluation of mucosal disease in the esophagus. The now-widespread deployment of the device into gastrointestinal practice in the US and many other countries suggests that VCE has achieved mainstream utility. The development of similar competitor devices, and devices whose movement can be controlled, is in progress.

Diagnosis of small-bowel diseases in the era of capsule endoscopy

Capsule endoscopy is a major breakthrough in gastrointestinal endoscopy and is a first-line tool to detect abnormalities of the small bowel, in up to 50% of patients, intestinal disorders are not associated with any physical findings or positive tests. Indications, yield and impact on patient management of this method of diagnosing small-bowel diseases are analyzed critically in light of current scientific knowledge.

The utility of capsule endoscopy and its role for diagnosing pathology in the gastrointestinal tract

BACKGROUND

Capsule endoscopy (CE) is a new device that enables visualization of areas of the small bowel that were previously inaccessible through other noninvasive procedures. The purpose of this study is to evaluate this new diagnostic tool and its efficacy in finding occult GI tract pathology.

METHODS

A single-institution retrospective review was completed on patients undergoing CE from January 2002 to September 2004. Data evaluated included indications for CE, results of previous studies, CE findings, and complications of the CE study.

RESULTS

A total of 702 CE studies in 652 patients were performed during the study period. Suspicious GI bleeding presenting as anemia, guaiac positive stools, or history of gross bleeding were the most common reasons to perform CE (75.8%). Other indications included abdominal pain (11.5%), diarrhea (3.1%), or others (9.5%). In studies performed for GI bleeding (N = 532), a source was found in 49.3% of CE studies. Arteriovenous malformation (AVM) was the most common reported finding (43.9%), followed by ulcer (24.1%), colon or gastric pathology (14.1%), mass/tumor (9.1%), and stricture (6.9%). Patients with abdominal pain (n = 81) had findings 46.9% of the time including edema/ulcer (47.4%), stricture (10.5%), mass/tumor (26.3%), gastric pathology (10.5%), AVM (2.6%), or sprue (2.6%). Patients with diarrhea (n = 22) had findings 45.5% of the time including edema/ulcer (75%), mass/tumor (12.5%), or sprue (12.5%). A total of 66 patients underwent operative exploration after a CE study at this institution either because of the observed findings or for other reasons. There were 12 (1.7%) CE studies in which the capsule was retained and required surgical removal. Pathology at the retention site included benign strictures or adhesions (n = 9, 75%), Crohn's stricture (n = 1, 8.3%) carcinoid tumor (n = 1, 8.3%), and villous adenoma (n = 1, 8.3%).

CONCLUSIONS

CE is an accurate study to locate abnormalities in the GI tract that may have either been missed by previous diagnostic studies or cannot be observed through other non-invasive means. When used for diagnostic challenges such as GI bleeding with no apparent source, CE can be helpful in guiding surgical decisions in patients and thus should be integrated as part of the diagnostic workup.

Capsule endoscopy: practical applications

Few advances in the history of gastroenterology have made as dramatic an impact on the diagnosis of gastrointestinal disease as the development and rapid clinical implementation of wireless capsule endoscopy. Less than 4 years after the landmark publication, capsule endoscopy is widely considered an essential component of the diagnostic workup of obscure gastrointestinal bleeding, and its role is expanding in the diagnosis of small bowel diseases such as Crohn's disease. This review appraises the available literature and highlights practical aspects of capsule endoscopy of interest to the clinician. We discuss safety concerns, optimal preparation for the procedure, diagnostic utility as compared to conventional methods, indications for capsule endoscopy, and outcomes.

Capsule endoscopy: current indications and future prospects

Capsule endoscopy represents a significant advance in the investigation of small bowel diseases and the beginning of wireless endoscopic imaging. Capsule endoscopy involves swallowing a video capsule endoscope, which is painless and relatively safe. Its use has been established for suspected small bowel bleeding, and the role of capsule endoscopy in the investigation of inflammatory bowel disease, iatrogenic disease, polyposis syndromes and coeliac disease is evolving. It is likely that in many instances it will become the next test after standard endoscopic evaluation. Early data suggest that capsule endoscopy improves outcome in patients with suspected small bowel bleeding, but more data are required on outcomes for the other indications.