The value of wireless capsule endoscopy in patients with complicated celiac disease

Guidelines for best practices in monitoring established coeliac disease in adult patients

Coeliac disease (CeD) is an immunological disease triggered by the consumption of gluten contained in food in individuals with a genetic predisposition. Diagnosis is based on the presence of small bowel mucosal atrophy and circulating autoantibodies (anti-type 2 transglutaminase antibodies). After diagnosis, patients follow a strict, life-long gluten-free diet. Although the criteria for diagnosis of this disease are well defined, the monitoring phase has been studied less and there is a lack of specific guidelines for this phase. To develop a set of clinical guidelines for CeD monitoring, we followed the Grading of Recommendations Assessment, Development and Evaluation methodology. Statements and recommendations with the level of evidence were developed and approved by the working group, which comprised gastroenterologists, pathologists, dieticians and biostatisticians. The proposed guidelines, endorsed by the North American and European coeliac disease scientific societies, make recommendations for best practices in monitoring patients with CeD based on the available evidence. The evidence level is low for many topics, suggesting that further research in specific aspects of CeD would be valuable. In conclusion, the present guidelines support clinicians in improving CeD treatment and follow-up and highlight novel issues that should be considered in future studies.

Diagnostic yield of inpatient capsule endoscopy

Background

Capsule endoscopy (CE) provides a novel approach to evaluate obscure gastrointestinal bleeding. Yet CE is not routinely utilized in the inpatient setting for a variety of reasons. We sought to identify factors that predict complete CE and diagnostically meaningful CE, as well as assess the impact of inpatient CE on further hospital management.1 na d2

Methods

We conducted a retrospective review of patients undergoing inpatient CE at a tertiary referral, academic center over a 3 year period. We analyzed data on patient demographics, medical history, endoscopic procedures, hospital course, and results of CE. The primary outcome was complete CE and the secondary outcome was positive findings of pathology on CE.

Results

131 patients were included (56.5% were men 43.5% women, median age of 71.0 years). Overall, CE was complete in 77.1% of patients. Complete CE was not related to motility risk factors, gender, or administration modality. Patients with incomplete CE tended to be older, have lower BMI, and Caucasian, however results did not reach statistical significance (p = 0.06; p = 0.06; p = 0.08 respectively). Positive CE was noted in 73.3% of patients, with 35.1% of all patients having active bleeding. Positive CE was not associated with AVM risk factors or medication use. 28.0% of patients underwent subsequent hospital procedures, among which 67.6% identified the same pathology seen on CE.

Conclusions

Contrary to previous studies, we found the majority of inpatient CEs were complete and positive for pathology. We found high rates of correlation between CE and subsequent procedures. The use of CE in the inpatient setting helps to guide the diagnosis and treatment of hospitalized patients with obscure gastrointestinal bleeding.

Celiac Disease Detection From Videocapsule Endoscopy Images Using Strip Principal Component Analysis

The purpose of this study was to implement principal component analysis (PCA) on videocapsule endoscopy (VE) images to develop a new computerized tool for celiac disease recognition. Three PCA algorithms were implemented for feature extraction and sparse representation. A novel strip PCA (SPCA) with nongreedy L1-norm maximization is proposed for VE image analysis. The extracted principal components were interpreted by a non-parametric k-nearest neighbor (k-NN) method for automated celiac disease classification. A benchmark dataset of 460 images (240 from celiac disease patients with small intestinal villous atrophy versus 220 control patients lacking villous atrophy) was constructed from the clinical VE series. It was found that the newly developed SPCA with nongreedy L1-norm maximization was most efficient for computerized celiac disease recognition, having a robust performance with an average recognition accuracy of 93.9 percent. Furthermore, SPCA also has a reduced computation time as compared with other methods. Therefore, it is likely that SPCA will be a helpful adjunct for the diagnosis of celiac disease.

Detection and Classification of Gastrointestinal Diseases using Machine Learning

BACKGROUND

Traditional endoscopy is an invasive and painful method of examining the gastrointestinal tract (GIT) not supported by physicians and patients. To handle this issue, video endoscopy (VE) or wireless capsule endoscopy (WCE) is recommended and utilized for GIT examination. Furthermore, manual assessment of captured images is not possible for an expert physician because it's a time taking task to analyze thousands of images thoroughly. Hence, there comes the need for a Computer-Aided-Diagnosis (CAD) method to help doctors analyze images. Many researchers have proposed techniques for automated recognition and classification of abnormality in captured images.

METHODS

In this article, existing methods for automated classification, segmentation and detection of several GI diseases are discussed. Paper gives a comprehensive detail about these state-of-theart methods. Furthermore, literature is divided into several subsections based on preprocessing techniques, segmentation techniques, handcrafted features based techniques and deep learning based techniques. Finally, issues, challenges and limitations are also undertaken.

RESULTS

A comparative analysis of different approaches for the detection and classification of GI infections.

CONCLUSION

This comprehensive review article combines information related to a number of GI diseases diagnosis methods at one place. This article will facilitate the researchers to develop new algorithms and approaches for early detection of GI diseases detection with more promising results as compared to the existing ones of literature.

Small bowel capsule endoscopy in refractory celiac disease: a luxury or a necessity?

Background

Small bowel capsule endoscopy (SBCE) has an established role in the management of refractory celiac disease (RCD) for the detection of complications. The aim of this study was to define the role of SBCE in the management of patients with RCD.

Method

Patients with histologically confirmed RCD who underwent successive SBCEs were recruited retrospectively from 2 tertiary centers.

Results

Sixty patients with RCD were included. The percentage extent of the affected small bowel (SB) mucosa improved on repeating a second SBCE in 26 patients (49.1%) (median 27.6% vs. 18.1%, P=0.007). Patients with RCD type II had more extensive disease than those with RCD type I on first (41.4% vs. 19.2%, P=0.004) and second (29.8% vs. 12.0%, P=0.016) SBCE. Patients with RCD type I tended to show a greater improvement in percentage of abnormal SB involved on repeat SBCE compared to those with RCD type II (P=0.049). Nine patients (15%) had RCD-related complications. Five patients developed ulcerative jejunoileitis, 3 patients developed enteropathy-associated T-cell lymphoma, and 1 patient developed cutaneous T-cell lymphoma.

Conclusions

SBCE can be a useful tool for monitoring the effects of treatment, primarily following its initiation. Patients with RCD type II have more extensive SB disease, equating to a more aggressive disease pattern.

Capsule endoscopy - Recent developments and future directions

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Use of small-bowel capsule endoscopy in cases of equivocal celiac disease

BACKGROUND AND AIMS

Seronegative villous atrophy (SNVA), raised intraepithelial lymphocytes (IELs), and crypt hyperplasia on duodenal histology can be secondary to celiac disease (CD) or other causes such as medications or infections. Our aims were to assess the role of small-bowel capsule endoscopy (SBCE) in these patients and to ascertain whether findings on SBCE at diagnosis can predict disease outcome.

METHODS

Patients (n = 177) with SNVA, IELs, ± crypt hyperplasia on duodenal histology were studied. These patients all had an equivocal diagnosis of CD.

RESULTS

Overall, 56 patients (31.6%) had a positive SBCE. Thirty-three patients (58.9%) had disease affecting the proximal third of the small bowel (SB). The diagnostic yield of SBCE was 40.0% (22 patients), 51.4% (18 patients), 27.0% (10 patients), and 14.0% (7 patients) in patients with an unknown cause for SNVA (SNVA-UO), patients with SNVA who responded to a gluten-free diet (SNVA-CD), patients with a known cause for SNVA, and patients with railed IELs ± crypt hyperplasia, respectively. In SNVA-UO, SBCE at diagnosis was more likely to be positive in patients with persistent SNVA (10, 90.9%) and persistent SNVA with lymphoproliferative features (4, 80.4%) than patients with spontaneous resolution of SNVA (8, 20.5%) (P = .0001). All patients in the SNVA-CD group who eventually developed adverse events had a positive SBCE (P = .022). They also had more extensive SB disease than those without adverse events (50% vs 1% P = .002). More extensive SB disease on SBCE correlated with a higher SNVA-related mortality in patients with SNVA-UO and SNVA-CD (P = .019). Severity of histology did not correlate with mortality (P = .793).

CONCLUSIONS

A positive SBCE at diagnosis predicts a worse outcome. More importantly, more extensive disease in these patients is associated with poor survival. Targeting patients with extensive disease at diagnosis with more aggressive therapy can help to improve prognosis.

Refractory coeliac disease: what should we be doing different?

PURPOSE OF REVIEW

The aim of this review is to provide insight into the diagnosis and management of patients with refractory coeliac disease (RCD) and highlight recent advances in this field.

RECENT FINDINGS

The diagnosis of RCD can be more accurately confirmed with flow cytometry in addition to immunohistochemistry. Dietary input and excretion of gluten immunogenic peptides can help rule out gluten contamination, and therefore, substantiate a diagnosis of RCD type I. Small bowel capsule endoscopy (SBCE) is important at diagnosis and follow-up in addition to duodenal histology. Apart from ruling out complications, it can give information on extent of disease in the small bowel, and therefore, help assess response to therapy. Those patients with a poor response can have earlier intensification of therapy, which may result in an improved outcome. RCD also occurs in patients with serology negative coeliac disease but with an increased mortality compared with patients with serology-positive coeliac disease.

SUMMARY

Patients with RCD can present with persistent symptoms of malnutrition but can also be completely asymptomatic. Serology is not a reliable marker to detect refractory disease. Immunostaining and flow cytometry are necessary for a diagnosis of RCD. Small bowel endoscopy enables disease extent to be assessed and allows for small bowel biopsies to be taken in case of suspicious lesions. Small bowel radiology can be complementary to small bowel endoscopy.

A Case of Intussusception in a Patient with Marijuana Use: Coincidence or Possible Correlation?

'Intussusception' means invaginating or telescoping and is caused by any condition that disrupts the normal physiological mechanism of intestinal peristalsis. Intussusception is rare in adults with an incidence of two to three cases per population of 1,000,000 annually. The most common cause of intussusception in adults is a neoplasm. In this case report, we are describing the case of a 22-year-old female with a past medical history of chronic constipation and a 60-pound unintentional weight loss who presented with the sudden onset of progressively worsening, severe abdominal pain associated with nausea, episodes of non-bloody, non-bilious emesis, and dark-colored loose stools. The patient's social history was significant for extensive marijuana use for more than one year. Upon presentation, vitals were significant for mild bradycardia and examination was remarkable for diffuse abdominal pain. Initial laboratory testing was positive only for lactic acidosis. A computed tomography (CT) scan of the abdomen and pelvis revealed small bowel intussusception in the left hemiabdomen, along with periportal edema, and a small amount of pericholecystic fluid. The patient underwent both upper endoscopy and colonoscopy but no lead points for the intussusception could be identified. The patient responded to conservative management, including bowel rest, which resulted in the resolution of the intussusception on a follow-up small bowel series. Intraluminal irritants as the possible etiology of intussusception should be considered in the absence of a pathological lead point. Marijuana has been shown to act on various bowel segments and disrupts gastrointestinal motility through inhibition of cholinergic mechanisms. We believe the chronic use of marijuana could be the possible etiology of intussusception observed in our patient. Therefore, this case brings attention to the adverse effects of marijuana in light of increasing legalization and the increasing therapeutic use of marijuana and its derivatives.

Prevalence of gastrointestinal malignancy in iron deficiency without anaemia: A systematic review and meta-analysis

BACKGROUND

Iron deficiency anaemia is associated with gastrointestinal (GI) malignancy and is an indication for GI investigations. However, the relevance of iron deficiency without anaemia (IDWA) and the underlying risks of GI malignancy are uncertain. Therefore, the aim of this study was to estimate the prevalence of GI malignancy in patients with IDWA overall and in clinically relevant subgroups.

METHODS

We searched MEDLINE and EMBASE for studies that reported on the prevalence or risk of GI malignancy in patients with confirmed IDWA. We performed a random effects meta-analysis of proportions and assessed statistical heterogeneity using the I² statistic.

RESULTS

A total of 1923 citations were screened and 5 studies (4 retrospective cohorts, 1 prospective cohort) comprising 3329 participants with IDWA were included in the meta-analysis. Overall pooled random-effects estimates for prevalence of GI malignancy in those with IDWA were low (0.38%, 95% CI 0.00%-1.84%, I2 = 87.7%). Older patients (2.58%, 95% CI 0.00%-8.77%); non-screening populations (2.45%, 95% CI 0.16%-6.39%) and men and post-menopausal women (0.90%, 95% CI 0.11%-3.23%) with IDWA were at increased risk of GI malignancy compared to younger patients (0.00%, 95% CI 0.00%-0.21%); screened populations (0.24%, 95% CI 0.00%-1.10%) and pre-menopausal women (0.00%, 95% CI 0.00%-1.05%).

CONCLUSION

Overall, IDWA is associated with a low risk of GI malignancy. Older patients and non-screening populations are at elevated risk and require GI investigations. Those not in these subgroups have a lower risk of GI malignancy and may wish to be monitored following discussion of the risk and potential benefits of GI investigations.

Capsule Endoscopy and Enteroscopy in Celiac Disease

Celiac disease predominantly involves the proximal small bowel, but villus atrophy can be patchy, spare the duodenum, and be present more distally. Video capsule endoscopy is more sensitive than standard endoscopy to detect villus atrophy, and can define extent of disease, though it cannot obtain biopsies. Duodenal biopsy is the gold standard for diagnosis. Video capsule endoscopy assists in special circumstances when biopsy is not possible, and in equivocal diagnosis. Video capsule endoscopy and enteroscopy are recommended for evaluating complicated celiac disease, especially refractory celiac disease type II. Future developments include computer-assisted capsule programs and advanced capsule and enteroscope design.

Capsule Endoscopy in Refractory Diarrhea-Predominant Irritable Bowel Syndrome and Functional Abdominal Pain

BACKGROUND/AIMS

Capsule endoscopy is a diagnostic method for evaluating the small bowel lumen and can detect undiagnosed lesions. The aim of this study was to evaluate the diagnostic yield and clinical impact of capsule endoscopy in patients with refractory diarrhea-predominant irritable bowel syndrome and functional abdominal pain.

METHODS

This study involved a retrospective analysis of prospectively collected data, maintained in a database. Patients with refractory diarrhea-predominant irritable bowel syndrome and functional abdominal pain within the period of March 2012 to March 2014 were included. Capsule endoscopy was used to detect small bowel pathologies in both groups.

RESULTS

Sixty-five patients (53.8% female) fulfilled the inclusion criteria and had a mean (±standard deviation) age of 50.9±15.9 years. Clinically significant lesions were detected via capsule endoscopy in 32.5% of the patients in the abdominal pain group and 54.5% of the patients in the diarrhea group. Overall, 48% of patients had small bowel pathologies detected during the capsule endoscopy study. Inflammatory lesions and villous atrophy were the most frequent lesions identified in 16.9% and 15.3% of patients in the abdominal pain and the diarrhea groups, respectively.

CONCLUSION

Routine use of capsule endoscopy in patients with irritable bowel syndrome should not be recommended. However, in patients with refractory conditions, capsule endoscopy may identify abnormalities.

Capsule endoscopy for patients with coeliac disease

Coeliac disease is an autoimmune mediated condition in response to gluten. A combination of innate and adaptive immune responses results in villous shortening in the small bowel (SB) that can be morphologically picked up on capsule endoscopy. It is the only imaging modality that can provide mucosal views of the entire SB, while histology is generally limited to the proximal SB. Radiological modalities are not designed to pick up changes in villous morphology. Areas covered: In this review, we provide a comprehensive analysis on the justified use of small bowel capsule endoscopy (SBCE) in the assessment of patients with coeliac disease; compare SBCE to histology, serology, and symptomatology; and provide an overview on automated quantitative analysis for the detection of coeliac disease. We also provide insight into future work on SBCE in relation to coeliac disease. Expert commentary: SBCE has opened up new avenues for the diagnosis and monitoring of patients with coeliac disease. However, larger studies with new and established coeliac disease patients and with greater emphasis on morphological features on SBCE are required to better define the role of SBCE in the setting of coeliac disease.

Role of capsule endoscopy in alarm features and non-responsive celiac disease: A European multicenter study

BACKGROUND AND AIM

The role of capsule endoscopy (CE) in established celiac disease (CD) remains unclear. Our objective was to analyze the usefulness of CE in the suspicion of complicated CD.

METHODS

This was a retrospective multicenter study. One hundred and eighty-nine celiac patients (mean age: 46.6 ± 16.6, 30.2% males) who underwent CE for alarm symptoms (n = 86, 45.5%) or non-responsive CD (n = 103, 54.5%) were included. Diagnostic yield (DY), therapeutic impact and safety were analyzed.

RESULTS

Capsule endoscopy was completed in 95.2% of patients (small bowel transit time: 270.5 ± 100.2 min). Global DY was 67.2%, detecting atrophic mucosa (n = 92, 48.7%), ulcerative jejunoileitis (n = 21, 11.1%), intestinal lymphoma (n = 7, 3.7%) and other enteropathies (n = 7, 3.7%, six Crohn's disease cases and one neuroendocrine tumor). The DY of CE was significantly higher in patients presenting with non-responsive disease compared to patients with alarm symptoms (73.8% vs 59.3%, P = 0.035). The new findings of the CE modified management in 59.3% of the cases. There were no major complications.

CONCLUSION

Capsule endoscopy may be a moderately helpful and safe diagnostic tool in the suspicion of complicated CD, modifying the clinical course of these patients.

Initial experience of video capsule endoscopy at a tertiary center in Saudi Arabia

BACKGROUND/AIM

No prior experience with video capsule endoscopy (VCE) has been published from Saudi Arabia. In this study, we aim to report the first Saudi experience with VCE.

PATIENTS AND METHODS

A prospective study was conducted between March 2013 and September 2017 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Eligible patients underwent VCE and their data (age, sex, indication for VCE, type of obscure gastrointestinal bleeding [OGIB: overt vs occult], VCE findings, and complications) were recorded. Approval was obtained from the institutional ethics board before the study began and all patients provided verbal and signed consent for the procedure. The procedure was performed according to the established guidelines.

RESULTS

During the study period, a total 103 VCE procedures were performed on 96 patients. Overall, 60 participants (62.5%) were male (mean age, 58.8 years; range, 25-97 years) and 36 (37.5%) were female (mean age, 52.8 years; range, 18-78 years). The most frequent indication for VCE was OGIB (n = 91, 88.35%; overt, n = 46, 50.55%; occult, n = 45, 49.45%). Other indications were suspected Crohn's disease (n = 4, 3.88%), suspected complicated celiac disease (n = 4, 3.88%), and unexplained chronic abdominal pain (n = 4, 3.88%). The VCE results were categorized as incomplete (n = 2, 1.94%), poor-quality (n = 7; 6.8%), normal (n = 39, 37.86%), and abnormal (n = 55, 53.4%). The completion rate was 98.06% (n = 101), and the overall diagnostic yield was 53.4%. Of the 55 patients with abnormal VCE results, 43 (78.2%) had small bowel (SB) abnormalities and 12 (21.8%) had abnormalities in the proximal or distal gut. The most frequent SB abnormalities were angiodysplasia (n = 22, 40.0%) and tumors (n = 7, 12.7%).

CONCLUSION

The diagnostic yield of VCE for Saudi patients with OGIB is comparable to that reported internationally; however, data for other VCE indications, including inflammatory bowel disease, are still lacking.

Use of enteroscopy for the detection of malignant and premalignant lesions of the small bowel in complicated celiac disease: a meta-analysis

BACKGROUND AND AIMS

Enteroscopy (wireless or wired) is the reference standard for small-bowel (SB) diseases, and it has been applied to detect SB malignancies in complicated celiac disease (CD) with heterogeneous results. The aim of this meta-analysis was to obtain a diagnostic yield (DY) by pooling the data of studies that investigated the use of enteroscopy to detect SB adverse events in CD.

METHODS

We performed an online search for studies estimating the DY of wireless and wired enteroscopy in predicting the presence of SB premalignant and/or malignant lesions. The DerSimonian and Laird random-effects method was used to pool the arcsine-transformed proportions of patients with the events. Three meta-analyses were performed considering the following events: the presence of a malignancy, premalignant damage (ulcerative jejunoileitis [UJ]), or the presence of a malignancy or UJ. A subgroup analysis was performed after extracting (if possible) patients with refractory CD (RCD).

RESULTS

Of the 529 titles initially resulting from the search, 10 studies on capsule enteroscopy (CE) and 3 on double-balloon or push enteroscopy met the inclusion criteria. Overall, 439 and 76 patients were enrolled in these studies using CE and enteroscopy, respectively. Twelve tumors and 47 UJs were found by CE versus 8 tumors and 13 UJs detected by wired enteroscopy. For malignancies the CE yield was 1.9% (95% CI, .5%-3.8%) and wired enteroscopy yield 8.7% (95% CI, 0%-21.2%); similarly, for UJ the DYs were 8.4% (95% CI, 2.1%-17.7%) and 16.7% (95% CI, 8.7%-26.3%); for either UJ or neoplasia the DYs were 13.0% (95% CI, 5.6%-22.5%) and 27.7% (95% CI, 14.8%-42.6%). For RCD the DYs of all enteroscopic techniques were 1.8% (95% CI, 0%-7.7%) for neoplasia, 22.3% (95% CI, 8.2%-39.7%) for UJ, and 27.5% (95% CI, 13.1%-44.2%) for either.

CONCLUSIONS

Enteroscopy is a powerful and efficient diagnostic tool for the detection of SB malignancies in complicated CD.

Guideline for wireless capsule endoscopy in children and adolescents: A consensus document by the SEGHNP (Spanish Society for Pediatric Gastroenterology, Hepatology, and Nutrition) and the SEPD (Spanish Society for Digestive Diseases)

INTRODUCTION

Capsule Endoscopy (CE) in children has limitations based mainly on age. The objective of this consensus was reviewing the scientific evidence.

MATERIAL AND METHODS

Some experts from the Spanish Society of Gastroenterology (SEPD) and Spanish Society for Pediatric Gastroenterology, Hepatology, and Nutrition (SEGHNP) were invited to answer different issues about CE in children. These sections were: a) Indications, contraindications and limitations; b) efficacy of CE in different clinical scenarios; c) CE performance; d) CE-related complications; e) Patency Capsule; and f) colon capsule endoscopy. They reviewed relevant questions on each topic.

RESULTS

The main indication is Crohn's disease (CD). There is no contraindication for the age and in the event that the patient not to swallow it, it should be administered under deep sedation with endoscopy and specific device. The CE is useful in CD, for the management of OGIB in children and in Peutz-Jeghers syndrome (in this indication has the most effectiveness). The main complication is retention, which should be specially taken into account in cases of CD already diagnosed with malnutrition. A preparation regimen based on a low volume of polyethylene glycol (PEG) the day before plus simethicone on the same day is the best one in terms of cleanliness although does not improve the results of the CE procedure.

CONCLUSIONS

CE is safe and useful in children. Indications are similar to those of adults, the main one is CD to establish both a diagnosis and disease extension. Moreover, only few limitations are detected in children.

Lack of benefit of active preparation compared with a clear fluid-only diet in small-bowel visualization for video capsule endoscopy: results of a randomized, blinded, controlled trial

BACKGROUND AND AIMS

Controversy remains regarding the type and amount of precapsule bowel cleansing required for small-bowel video capsule endoscopy (VCE). This study aims to assess the efficacy and tolerance of 2 active preparations and a control group of clear fluids only.

METHODS

Patients with clinical indications for VCE were randomized to (1) clear fluids only the evening before VCE, (2) 2 sachets of sodium picosulfate plus magnesium sulfate (P/MC) the evening before, or (3) 2 L of polyethylene glycol (PEG) the evening before. Diet instructions were the same for all 3 groups. Small-bowel cleansing was assessed in 3 ways: a 5-point ordinal scale (primary outcome), the percentage of time the small-bowel view was clear, and a validated computerized assessment of cleansing.

RESULTS

In total, 198 patients were randomized and 175 patients completed the trial with a mean age of 49.2 years. There was no clear benefit of active preparation with either P/MC or PEG over clear fluids only in the overall 5-point rating scale or in the distal fourth of each examination. There was no difference in diagnostic yield between groups. Significant differences were seen concerning tolerance of the preparations, with a higher proportion rating it as easy or very easy in the clear fluids-only group (93%) and the P/MC group (67%) than in the PEG group (13%) (P < .0001).

CONCLUSIONS

Small-bowel cleansing for VCE remains a controversial topic. This randomized control trial demonstrates no benefit in overall or distal small-bowel visualization with active preparation using either PEG or P/MC compared with clear fluids only. (Clinical trial registration number: NCT00677794.).

Inflammatory Disorders of the Small Bowel

The most common small bowel inflammatory disorders include Crohn disease, nonsteroidal antiinflammatory drug (NSAID) enteropathy, and celiac disease. Capsule endoscopy, computed tomography enterography, and magnetic resonance enterography have a complementary role in the diagnosis of Crohn disease and evaluation of patients with established Crohn disease. The higher risk of capsule retention with known Crohn disease and NSAID enteropathy can be minimized by cross-sectional imaging or the patency capsule. The main role of deep enteroscopy is tissue diagnosis, endoscopic management of small bowel lesions and strictures, and retrieval of retained capsules.

Low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate, and clear liquid diet alone prior to small bowel capsule endoscopy

AIM: To compare low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate and clear liquid diet alone as bowel preparation prior to small bowel capsule endoscopy (CE).

METHODS: We retrospectively collected all CE studies done from December 2011 to July 2013 at a single institution. CE studies were reviewed only if low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate or clear liquid diet alone used as the bowel preparation. The studies were then reviewed by the CE readers who were blinded to the preparation type. Cleanliness and bubble burden were graded independently within the proximal, middle and distal small bowel using a four-point scale according to the percentage of small bowel mucosa free of debris/bubbles: grade 1 = over 90%, grade 2 = between 90%-75%, grade 3 = between 50%-75%, grade 4 = less than 50%. Data are expressed as mean ± SEM. ANOVA and Fishers exact test were used where appropriate. P values < 0.05 were considered statistically significant.

RESULTS: A of total of 123 CE studies were reviewed. Twenty-six studies were excluded from analysis because of incomplete small bowel examination. In the remaining studies, 39 patients took low volume polyethylene glycol with ascorbic acid, 31 took sodium picosulfate-magnesium citrate and 27 took a clear liquid diet alone after lunch on the day before CE, followed by overnight fasting in all groups. There was no significant difference in small bowel cleanliness (1.98 ± 0.09 vs 1.84 ± 0.08 vs 1.76 ± 0.08) or small bowel transit time (213 ± 13 vs 248 ± 14 ± 225 ± 19 min) for clear liquid diet alone, MoviPrep and Pico-Salax respectively. The bubble burden in the mid small bowel was significantly higher in the MoviPrep group (1.6 ± 0.1 vs 1.9 ± 0.1 vs 1.6 ± 0.1, P < 0.05). However this did not result in a significant difference in diagnosis of pathology.

CONCLUSION: There was no significant difference in small bowel cleanliness or diagnostic yield of small bowel CE between the three preparations regimens used in this study.

Enteroscopy and radiology for the management of celiac disease complications: Time for a pragmatic roadmap

Celiac disease is the most common autoimmune enteropathy in Western countries, and is usually associated with a good response to the gluten free diet and an excellent prognosis. However, a minority of patients develop complications of the disease, such as refractory celiac disease, ulcerative jejunoileitis and neoplastic complications such as adenocarcinoma of the small bowel and enteropathy associated T cell lymphoma. Neoplastic complications described in association with celiac disease have a high mortality rate, due to their aggressive behavior and to the usual advanced stage at the time of diagnosis. In recent years, the detection of small bowel lesions has dramatically improved thank to the availability of highly performing radiologic and endoscopic techniques. The diagnostic delay of malignant complications in patients with celiac disease may be improved by establishing a pragmatic flowchart for the identification and follow up of "at risk" patients. We performed a comprehensive review of the articles published on this issue in order to promote a roadmap to be applied when facing with celiac patients with suspected small bowel complications.

A Review of Locomotion Systems for Capsule Endoscopy

Wireless capsule endoscopy for gastrointestinal (GI) tract is a modern technology that has the potential to replace conventional endoscopy techniques. Capsule endoscopy is a pill-shaped device embedded with a camera, a coin battery, and a data transfer. Without a locomotion system, this capsule endoscopy can only passively travel inside the GI tract via natural peristalsis, thus causing several disadvantages such as inability to control and stop, and risk of capsule retention. Therefore, a locomotion system needs to be added to optimize the current capsule endoscopy. This review summarizes the state-of-the-art locomotion methods along with the desired locomotion features such as size, speed, power, and temperature and compares the properties of different methods. In addition, properties and motility mechanisms of the GI tract are described. The main purpose of this review is to understand the features of GI tract and diverse locomotion methods in order to create a future capsule endoscopy compatible with GI tract properties.

Engineering Micromechanical Systems for the Next Generation Wireless Capsule Endoscopy

Wireless capsule endoscopy (WCE) enables the detection and diagnosis of inflammatory bowel diseases such as Crohn's disease and ulcerative colitis. However treatment of these pathologies can only be achieved through conventional means. This paper describes the next generation WCE with increased functionality to enable targeted drug delivery in the small intestinal tract. A prototype microrobot fabricated in Nylon 6 is presented which is capable of resisting peristaltic pressure through the deployment of an integrated holding mechanism and delivering targeted therapy. The holding action is achieved by extending an “anchor” spanning a 60.4 mm circumference, for an 11.0 mm diameter WCE. This function is achieved by a mechanism that occupies only 347.0 mm³ volume, including mechanics and actuator. A micropositioning mechanism is described which utilises a single micromotor to radially position and then deploy a needle 1.5 mm outside the microrobot's body to deliver a 1 mL dose of medication to a targeted site. An analysis of the mechanics required to drive the holding mechanism is presented and an overview of microactuators and the state of the art in WCE is discussed. It is envisaged that this novel functionality will empower the next generation of WCE to help diagnose and treat pathologies of the GI tract.

Suggestions for automatic quantitation of endoscopic image analysis to improve detection of small intestinal pathology in celiac disease patients

Although many groups have attempted to develop an automated computerized method to detect pathology of the small intestinal mucosa caused by celiac disease, the efforts have thus far failed. This is due in part to the occult presence of the disease. When pathological evidence of celiac disease exists in the small bowel it is visually often patchy and subtle. Due to presence of extraneous substances such as air bubbles and opaque fluids, the use of computerized automation methods have only been partially successful in detecting the hallmarks of the disease in the small intestine-villous atrophy, fissuring, and a mottled appearance. By using a variety of computerized techniques and assigning a weight or vote to each technique, it is possible to improve the detection of abnormal regions which are indicative of celiac disease, and of treatment progress in diagnosed patients. Herein a paradigm is suggested for improving the efficacy of automated methods for measuring celiac disease manifestation in the small intestinal mucosa. The suggestions are applicable to both standard and videocapsule endoscopic imaging, since both methods could potentially benefit from computerized quantitation to improve celiac disease diagnosis.

Videocapsule endoscopy in celiac disease: indications and timing

BACKGROUND

Because of its technical characteristics (i.e. 8-fold magnification, capability to inspect the entire small bowel) and minimal invasiveness, videocapsule endoscopy (VCE) has been proposed as a useful tool for managing patients with celiac disease (CD).

KEY MESSAGES

Although VCE has been found to be highly sensitive and specific in identifying CD endoscopic markers, it is still inadequate to replace esophagogastroduodenoscopy (EGD) with biopsies in the diagnosis of CD. Nevertheless, it represents a reliable alternative in patients unable or unwilling to undergo EGD. Up to now, available studies have failed to identify any correlation between the length of small bowel involvement and the severity of symptoms. The available evidence on the use of VCE in diagnosing CD in equivocal cases (patients with positive serology and negative or nonspecific histology or those with negative serology and histologically proven villous atrophy) is limited, and its role is still under discussion. In CD patients not improving on gluten-free diet, a complete workup is necessary. In patients with nonresponsive (NRCD) or refractory CD (RCD), VCE has been shown to be able not only to detect significant findings, driving further management, but also to rule out major complications. Nevertheless, in this setting, the inability of VCE to take tissue samples and the risk of capsule retention can represent major limitations.

CONCLUSIONS

At the present time, for diagnostic purposes, VCE can be proposed only in patients unable or unwilling to undergo EGD, whereas it could be useful in some equivocal cases. Conversely, there is no room for VCE either to estimate the length of the small bowel affected by villous atrophy or to follow up patients improving on gluten-free diet. In patients with NRCD or RCD, VCE can play a role, but it should be combined with other diagnostic techniques.

Quantitative image analysis of celiac disease

We outline the use of quantitative techniques that are currently used for analysis of celiac disease. Image processing techniques can be useful to statistically analyze the pixular data of endoscopic images that is acquired with standard or videocapsule endoscopy. It is shown how current techniques have evolved to become more useful for gastroenterologists who seek to understand celiac disease and to screen for it in suspected patients. New directions for focus in the development of methodology for diagnosis and treatment of this disease are suggested. It is evident that there are yet broad areas where there is potential to expand the use of quantitative techniques for improved analysis in suspected or known celiac disease patients.

Diagnostic modalities for the evaluation of small bowel disorders

PURPOSE OF REVIEW

This review summarizes the recent developments in the evaluation of small bowel disorders using videocapsule endoscopy (VCE) and serological and breath-test biomarkers.

RECENT FINDINGS

The ability to visualize the small bowel was revolutionized with the introduction of VCE technology. VCE allows for accurate, noninvasive visualization of the small bowel mucosa. This device is invaluable in the investigation of obscure gastrointestinal bleeding (OGIB), occult bleeding with iron deficiency anaemia, small bowel Crohn's disease (CD), small bowel neoplasms and other mucosal disorders. Recent studies underscored the utility of VCE for documenting the extent and severity of small bowel CD as well as monitoring activity after therapy. The accuracy of the discrimination between small bowel tumours and benign bulges has been improved by a novel endoscopic algorithm. The accuracy of VCE was also evaluated as a potential noninvasive alternative to small bowel biopsies in suspected celiac disease. New findings have been made using breath tests and other biomarkers for the diagnosis of celiac disease, irritable bowel syndrome and bacterial overgrowth.

SUMMARY

VCE as well as breath-test biomarkers play a major and expanding role in the diagnosis and monitoring of various small bowel disorders.

Wireless capsule endoscopy: Perspectives beyond gastrointestinal bleeding

Wireless capsule endoscopy (CE) is a technology developed for the endoscopic exploration of the small bowel. The first capsule model was approved by the Food and Drug Administration in 2001, and its first and essential indication was occult gastrointestinal (GI) bleeding. Over subsequent years, this technology has been refined to provide superior resolution, increased battery life, and capabilities to view different parts of the GI tract. Indeed, cases for which CE proved useful have increased significantly over the last few years, with new indications for the small bowel and technical improvements that have expanded its use to other parts of the GI tract, including the esophagus and colon. The main challenges in the development of CE are new devices with the ability to provide therapy, air inflation for a better vision of the small bowel, biopsy sampling systems attached to the capsule and the possibility to guide and move the capsule with an external motion control. In this article we review the current and new indications of CE, and the evolving technological changes shaping this technology, which has a promising potential in the coming future of gastroenterology.

Wireless capsule endoscopy of the small intestine: a review with future directions

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.

Capsule endoscopy: Current practice and future directions

Capsule endoscopy (CE) has transformed investigation of the small bowel providing a non-invasive, well tolerated means of accurately visualising the distal duodenum, jejunum and ileum. Since the introduction of small bowel CE thirteen years ago a high volume of literature on indications, diagnostic yields and safety profile has been presented. Inclusion in national and international guidelines has placed small bowel capsule endoscopy at the forefront of investigation into suspected diseases of the small bowel. Most commonly, small bowel CE is used in patients with suspected bleeding or to identify evidence of active Crohn’s disease (CD) (in patients with or without a prior history of CD). Typically, CE is undertaken after upper and lower gastrointestinal flexible endoscopy has failed to identify a diagnosis. Small bowel radiology or a patency capsule test should be considered prior to CE in those at high risk of strictures (such as patients known to have CD or presenting with obstructive symptoms) to reduce the risk of capsule retention. CE also has a role in patients with coeliac disease, suspected small bowel tumours and other small bowel disorders. Since the advent of small bowel CE, dedicated oesophageal and colon capsule endoscopes have expanded the fields of application to include the investigation of upper and lower gastrointestinal disorders. Oesophageal CE may be used to diagnose oesophagitis, Barrett’s oesophagus and varices but reliability in identifying gastroduodenal pathology is unknown and it does not have biopsy capability. Colon CE provides an alternative to conventional colonoscopy for symptomatic patients, while a possible role in colorectal cancer screening is a fascinating prospect. Current research is already addressing the possibility of controlling capsule movement and developing capsules which allow tissue sampling and the administration of therapy.

Enteroscopy for the early detection of small bowel tumours in at-risk celiac patients

BACKGROUND

A subset of celiac patients shows a high risk for small bowel malignancies.

AIMS

To select celiac patients considered at risk and evaluate the diagnostic yield of enteroscopy in this context.

METHODS

Celiac patients were enrolled from a tertiary referral centre during the period June 2011-June 2013, based on the following criteria: (i) patients diagnosed when aged 50+ and with poor response to gluten-free dieting; (ii) low dietary compliance; (iii) alarm symptoms. The patients underwent small bowel capsule endoscopy and/or double-balloon enteroscopy. Control populations were represented by the 165 non-celiac patients undergoing capsule endoscopy for obscure gastrointestinal bleeding, and the 815,362-strong population of the Italian province of Varese as a registered cohort.

RESULTS

Fifty-three patients (19% males, mean age 43.6±17.4 years) were evaluated. Two jejunal adenocarcinomas and one ileal neuro-endocrine tumour were diagnosed by enteroscopy (the diagnostic yield for malignancies in the selected population being 5.7%). In the non-celiac controls the detection rate of small bowel tumours by capsule endoscopy was 0.6% (P=0.04). When compared to the registered population, the relative risk for intestinal malignancy was 1282 (95% CI, 407-4033; P<0.0001).

CONCLUSIONS

Capsule endoscopy and double-balloon enteroscopy can be considered for early disease management of a subset of celiac patients.

Increased diagnostic yield of capsule endoscopy in patients with chronic abdominal pain

Background and Study Aims

Chronic abdominal pain is one of the most common chief complaints, but the underlying pathophysiology often remains unknown after routine clinical evaluation. Capsule endoscopy (CE) is a new technique for the visualization of the entire small bowel. The aim of this study was to evaluate the diagnostic efficacy of CE in patients with chronic abdominal pain of obscure origin.

Patients and Methods

Two hundred forty three patients with chronic abdominal pain with no significant lesions were enrolled in this study. CE was performed in all patients.

Results

A diagnosis was made in 23.0% of patients screened with CE. Of the 243 patients, 19 (7.8%) were diagnosed with Crohn's disease, 15 (6.2%) with enteritis, 11 (4.5%) with idiopathic intestinal lymphangiectasia, 5 (2.1%) with uncinariasis, and a number of other diagnoses including small bowel tumor, ascariasis, and anaphylactoid purpura. Five patients had abnormal transit time, and capsule retention occurred in two patients.

Conclusions

In contrast to other previous studies, we found that CE is an effective diagnostic tool for patients with abdominal pain.

Wireless capsule endoscopy

Over the last decade, WCE has established itself as a valuable test for imaging the small intestine. It is a safe and relatively easy procedure to perform that can provide valuable information in the diagnosis of small-bowel conditions. Its applications still remain limited within the esophagus and colon. Future developments may include improving visualization within the esophagus and developing technologies that may allow manipulation of the capsule within the GI tract and biopsy capabilities.

Safety of capsule endoscopy in the octogenarian as compared with younger patients

BACKGROUND

There has been an increased use of capsule endoscopy for the evaluation of small-intestine pathology in very elderly patients, yet the safety profile of this procedure has not been well-established.

OBJECTIVE

To estimate the adverse event rate of capsule endoscopy in patients aged ≥80 years and to compare this rate with that of capsule endoscopy patients aged <80 years.

DESIGN

Retrospective matched cohort study.

SETTING

Single tertiary-care referral center.

PATIENTS

All 195 patients aged ≥80 years who underwent capsule endoscopy between 2005 and 2011 were included, along with 585 capsule endoscopy patients aged <80 years who were matched by sex in a 1:3 fashion.

INTERVENTION

All patients underwent capsule endoscopy and, in selected cases, double-balloon enteroscopy.

MAIN OUTCOME MEASUREMENTS

Adverse event rate of capsule endoscopy, which was defined as capsule retention or aspiration.

RESULTS

Adverse events occurred at a similar frequency in patients aged ≥80 years compared with those aged <80 years (1.03% vs 0.85%; P = 1.00), resulting in a difference of 0.2% (95% confidence interval, -1.8% to 2.1%). All adverse events were related to capsule retention, with no study patients experiencing aspiration.

LIMITATIONS

This was a single-center, retrospective study.

CONCLUSION

Adverse events resulting from capsule endoscopy occur at a similar rate in patients aged ≥80 years compared with those aged <80 years. Capsule endoscopy can be performed safely in the very elderly patient population.

Clinical applications of small bowel capsule endoscopy

Video capsule endoscopy has revolutionized our ability to visualize the entire small bowel mucosa. This modality is established as a valuable tool for the diagnosis of obscure gastrointestinal bleeding, Crohn's disease, small bowel tumors, and other conditions involving the small bowel mucosa. This review includes an overview of the current and potential future clinical applications of small bowel video endoscopy.

Clinical applications of small bowel capsule endoscopy

Video capsule endoscopy has revolutionized our ability to visualize the entire small bowel mucosa. This modality is established as a valuable tool for the diagnosis of obscure gastrointestinal bleeding, Crohn’s disease, small bowel tumors, and other conditions involving the small bowel mucosa. This review includes an overview of the current and potential future clinical applications of small bowel video endoscopy.

Video capsule endoscopy in patients with nonresponsive celiac disease

GOALS AND BACKGROUND

Discriminating between patients with nonresponsive but otherwise uncomplicated celiac disease (CD) and patients with refractory celiac disease (RCD) and/or lymphoma is difficult, especially as many abnormalities encountered in complicated CD are not within reach of conventional gastroduodenoscopy. We aimed to describe video capsule endoscopy (VCE) findings in patients with CD and persisting or relapsing symptoms despite a gluten-free diet and to identify VCE findings associated with poor prognosis.

METHODS

We retrospectively analyzed 48 VCE studies performed in adult patients with CD because of persisting or relapsing symptoms despite adherence to a gluten-free diet. Patients with either uncomplicated CD or RCD type I were considered to have a good prognosis, whereas patients with either RCD type II or enteropathy-associated T-cell lymphoma were considered to have a poor prognosis. Multivariate analysis was performed to identify VCE findings independently associated with either good or poor prognosis.

RESULTS

Proximal focal erythema (odds ratio, 6.7; 95% confidence interval, 1.2-38.7; P=0.033) and absence of progression of the capsule to the distal intestine (odds ratio, 16.5; 95% confidence interval, 1.2-224.9; P=0.035) were independently associated with poor prognosis. Of the 28 patients with none of these 2 features, none died during follow-up, compared with 2 (13.3%) of the 15 patients with one of both features, and 4 (80.0%) of the 5 patients with both the features.

CONCLUSIONS

VCE is a minimally invasive endoscopic modality that could be of use in identifying patients with nonresponsive CD who are at risk of poor prognosis.

ACG clinical guidelines: diagnosis and management of celiac disease

This guideline presents recommendations for the diagnosis and management of patients with celiac disease. Celiac disease is an immune-based reaction to dietary gluten (storage protein for wheat, barley, and rye) that primarily affects the small intestine in those with a genetic predisposition and resolves with exclusion of gluten from the diet. There has been a substantial increase in the prevalence of celiac disease over the last 50 years and an increase in the rate of diagnosis in the last 10 years. Celiac disease can present with many symptoms, including typical gastrointestinal symptoms (e.g., diarrhea, steatorrhea, weight loss, bloating, flatulence, abdominal pain) and also non-gastrointestinal abnormalities (e.g., abnormal liver function tests, iron deficiency anemia, bone disease, skin disorders, and many other protean manifestations). Indeed, many individuals with celiac disease may have no symptoms at all. Celiac disease is usually detected by serologic testing of celiac-specific antibodies. The diagnosis is confirmed by duodenal mucosal biopsies. Both serology and biopsy should be performed on a gluten-containing diet. The treatment for celiac disease is primarily a gluten-free diet (GFD), which requires significant patient education, motivation, and follow-up. Non-responsive celiac disease occurs frequently, particularly in those diagnosed in adulthood. Persistent or recurring symptoms should lead to a review of the patient's original diagnosis to exclude alternative diagnoses, a review of the GFD to ensure there is no obvious gluten contamination, and serologic testing to confirm adherence with the GFD. In addition, evaluation for disorders associated with celiac disease that could cause persistent symptoms, such as microscopic colitis, pancreatic exocrine dysfunction, and complications of celiac disease, such as enteropathy-associated lymphoma or refractory celiac disease, should be entertained. Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice. Given the incomplete response of many patients to a GFD-free diet as well as the difficulty of adherence to the GFD over the long term, development of new effective therapies for symptom control and reversal of inflammation and organ damage are needed. The prevalence of celiac disease is increasing worldwide and many patients with celiac disease remain undiagnosed, highlighting the need for improved strategies in the future for the optimal detection of patients.

Capsule endoscopy in adult celiac disease: a potential role in equivocal cases of celiac disease?

BACKGROUND

There have been limited studies evaluating capsule endoscopy (CE) in equivocal celiac disease (CD).

OBJECTIVE

To determine the role CE may have in equivocal CD cases, compared with patients with biopsy-proven and serology-proven CD who have persisting symptoms.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENTS

A total of 62 patients with equivocal CD and 69 patients with nonresponsive CD.

INTERVENTION

CE.

MAIN OUTCOME MEASUREMENTS

Diagnostic yield of CE in equivocal cases and accuracy of mucosal abnormality detection in patients with nonresponsive CD.

RESULTS

Equivocal cases (n = 62) were divided into two subgroups: group A (antibody-negative villous atrophy, n = 32) and group B (Marsh 1-2 changes, n = 30). In group A, CE secured a diagnosis of CD or Crohn's disease in 28% (9/32), significantly higher than the diagnostic yield in group B (7%; P = .044). In patients with CD with persisting symptoms, significant CE findings were identified in 12% (8/69), including 2 cases of enteropathy-associated lymphoma, 4 type 1 refractory disease cases, 1 polypoidal mass histologically confirmed to be a fibroepithelial polyp, and 1 case of ulcerative jejunitis. This outcome was significantly lower than the diagnostic yield of CE in antibody-negative villous atrophy (P = .048).

LIMITATIONS

Single center.

CONCLUSION

There have been no previous reports systematically evaluating equivocal CD by using CE. The diagnostic yield of CE in patients with antibody-negative villous atrophy is better than that of CE in patients with CD with persisting symptoms. We advocate the use of CE in equivocal cases, particularly in patients with antibody-negative villous atrophy.

Small bowel adenocarcinoma complicating coeliac disease: a report of three cases and the literature review

Coeliac disease is associated with an increased risk of malignancy, not only of intestinal lymphoma but also of small intestinal adenocarcinoma which is 82 times more common in patients with celiac disease than in the normal population. We report three additional cases of a small bowel adenocarcinoma in the setting of coeliac disease in order to underline the epidemiological features, clinicopathological findings, and therapeutic approaches of this entity based on a review of the literature. The three patients underwent a surgical treatment followed by adjuvant chemotherapy based on capecitabine/oxaliplatin regimen, and they have well recovered.

Transformation of videocapsule images to detect small bowel mucosal differences in celiac versus control patients

BACKGROUND

Videocapsule endoscopy can be useful to detect small intestinal pathology in celiac disease patients. However, presence of extraneous features including air bubbles and opaque fluids can complicate the analysis. A technique for quantitative analysis of videocapsule images is presented that is robust to presence of extraneous features.

METHOD

Videocapsule clips were acquired from five small intestinal locations in 12 celiacs with villous atrophy and 11 control patients. Clips were 200 frames in length, their resolution was 576 × 576 pixels and 256 grayscale levels, with 2/s frame rate. The dominant period (DP), defined as the tallest peak in the ensemble average power spectrum, was computed over each clip without removal of extraneous features. Ensemble average basis images were constructed, and measurements were made of their frame-to-frame variation in brightness and texture.

RESULTS

From pooled basis images, celiac images had greater texture than controls and exhibited more brightness variation (p<0.05 in mean and p<0.01 in standard deviation). In celiacs, correlation existed between greater textural alterations versus longer DP (r²=0.47), and between greater brightness variation and longer DP (r²=0.33). There was no significant correlation between quantitative features and DP in controls (r²<0.25).

CONCLUSIONS

Using this new method, celiac videoclips were quantitatively distinguishable from control videoclips without manual or computer-assisted detection, masking, and removal of extraneous image features. Furthermore, in celiac but not control basis images, larger textural and brightness alterations were correlated to longer DP. Greater textural and brightness alterations, and thus longer periodicities, are likely related to presence of villous atrophy.

Diagnostic yield of capsule endoscopy in refractory celiac disease

OBJECTIVES

Capsule endoscopy (CE) allows for the assessment of the small bowel in numerous intestinal diseases, including celiac disease (CD). The main advantage of CE is the complete visualization of the intestinal mucosal surface. The objective of this study was to investigate whether CE can predict the severity of CD and detect complications.

METHODS

We retrospectively studied the medical files of 9 patients with symptomatic CD, 11 patients with refractory celiac disease type I (RCDI) and 18 patients with refractory celiac disease type II (RCDII), and 45 patients without CD who were investigated both CE and upper endoscopy or enteroscopy. The type of CD was diagnosed on the basis of a centralized histological review, flow cytometry analysis of intraepithelial lymphocytes, and the analysis of T-cell receptor rearrangement by multiplex polymerase chain reaction.

RESULTS

A total of 47 CEs (10, 11, and 26 CEs in the symptomatic CD, RCDI, and RCDII groups, respectively) from the 38 celiac patients and 47 CEs from the 45 nonceliac patients were retrospectively reviewed. Villous atrophy, numerous, or distally located ulcers were more frequent in celiac patients than in controls. Among celiac patients, CE was of acceptable quality in 96% of cases and was complete in 62% of cases. The concordance of CE with histology for villous atrophy was better than that of optic endoscopy (κ coefficient =0.45 vs. 0.24, P<0.001). Extensive mucosal damage on CE was associated with low serum albumin (P=0.003) and the RCDII form (P=0.02). Three cases of overt lymphoma were detected by CE during the follow-up.

CONCLUSIONS

CE findings have a satisfactory concordance with histology and nutritional status in patients with symptomatic or refractory CD. Moreover, CE may predict the type of RCD and allows for the early detection of overt lymphoma.

Video capsule endoscopy in celiac disease

Video capsule endoscopy (VCE) provides a safe, non-invasive way to visualize the small intestine and is helpful in celiac disease patients in select situations. VCE can be performed in patients who are unable or unwilling to undergo conventional endoscopy, those with positive celiac serology with normal duodenal biopsies, and also in those who develop alarm symptoms. VCE has limitations including subjective interpretation. Techniques are being developed to standardize assessment of VCE images in patients with known or suspected celiac disease. Pilot studies using computer-based quantification methods have shown promise in examining the 3-dimensional mucosal structure and motility.

Is enteroscopy necessary for diagnosis of celiac disease?

Celiac disease (CD) is an autoimmune inflammatory disease of the small intestine as a result of reaction to wheat protein, gluten. Exclusion of dietary gluten is the mainstay of the treatment that necessitates a precise diagnosis of the disease. Serological screening may aid in identifying patients with suspected CD, which should be confirmed by intestinal biopsy. It has been shown that duodenal biopsies are good for detection of the disease in most patients. However, there is a group of patients with positive serology and inconclusive pathology. As a result of the widespread use of serology, many patients with equivocal findings grow quickly. Unfortunately current endoscopic methods can only diagnose villous atrophy, which can be present in the later grades of disease (i.e., Marsh III). To diagnose CD correctly, going deeper in the intestine may be necessary. Enteroscopy can reveal changes in CD in the intestinal mucosa in 10%-17% of cases that have negative histology at initial workup. Invasiveness of the method limits its use. Capsule endoscopy may be a good substitute for enteroscopy. However, both techniques should be reserved for patients with suspected diagnosis of complications. This paper reviews the current literature in terms of the value of enteroscopy for diagnosis of CD.

Diagnosing celiac disease by video capsule endoscopy (VCE) when esophagogastroduodenoscopy (EGD) and biopsy is unable to provide a diagnosis: a case series

Background

Video capsule endoscopy (VCE) is mainly used to evaluate patients with celiac disease in whom their course after diagnosis has been unfavorable and the diagnosis of adenocarcinoma, lymphoma or refractory celiac disease is entertained, but it has been suggested that VCE could replace esophagogastroduodenoscopy (EGD) and biopsy under certain circumstances.

Methods

We report a single center case series of 8 patients with suspected celiac disease who were diagnosed by VCE.

Results

EGD and biopsy had been performed in 4 patients resulting in a negative biopsy, declined by 2, and contraindicated in 2 due to hemophilia and von Willebrand disease. In all patients, mucosal changes of scalloping, mucosal mosaicism and reduced folds were seen in either the duodenum or jejunum on VCE. Follow-up in 7 patients demonstrated improvement in either their serological abnormalities or their presenting clinical features on a gluten-free diet.

Conclusions

Our case series demonstrates that VCE and the visualization of the characteristic mucosal changes of villous atrophy may replace biopsy as the mode of diagnosis when EGD is either declined or contraindicated, or when duodenal biopsies are negative and there remains a high index of suspicion. Further study is needed to clarify the role and cost of diagnosing celiac disease with VCE.

KIR/HLA combination associated with the risk of complications in celiac disease

The pathogenesis of celiac disease (CD) is associated with polymorphisms in human leukocyte antigen (HLA) genes; however, compelling evidence suggests that additional non-HLA genes are associated with CD and related complications. The present study investigated whether killer cell immunoglobulin-like receptor (KIR)/HLA gene combinations are associated with CD and its clinical complications in the population of northeast Italy. The study included 61 adults affected by CD: 48 patients were at first diagnosis and 13 patients had CD-related complications (8 with refractory CD and 5 with cancer). Controls were 69 blood donors genotyped for KIR and HLA. Several statistically significant differences emerged between CD patients and blood donors. The results herein presented show that susceptibility to CD with refractory disease or cancer is associated with various genotypes including the 2DS2/2DL2+C1, 2DS3, 3DL1, and 2DL5B genes. In addition, the absence of the Bw4 ligand may be a predisposing factor for cancer. These results suggest that a KIR haplotype and HLA ligands may be involved in the susceptibility to important clinical CD complications such as tumors or refractoriness as a result of a gluten-free diet.

Small bowel endoscopy and coeliac disease

Coeliac disease (CD) is a gluten-responsive, chronic inflammatory enteropathy that shares many features with classical autoimmune diseases. Coeliac disease affects about 1-2% of Caucasians, North Africans and Asians who possess the necessary susceptibility genes encoding HLA DQ2 or HLA DQ8. It is not only unique among the autoimmune diseases in that the precise trigger (gluten from wheat, rye and barley) has been identified, but also in that it has lent itself well to advancements in endoscopic imaging. Since its introduction, flexible endoscopy has allowed tissue to be collected from the small bowel with relative ease and safety, and recently has facilitated direct imaging and sampling of the entire small intestine. It is now fifty years since the Crosby capsule first allowed clinicians the ability to non-surgically biopsy the small bowel leading to an enhanced diagnosis of coeliac disease. The introduction of wireless video capsule endoscopy (VCE), small bowel enteroscopy and in particular double balloon enteroscopy (DBE), have expedited the accurate diagnosis of coeliac disease and its more serious complications such as small bowel adenocarcinoma, refractory coeliac disease type II (RCDII) and enteropathy associated T cell lymphoma (EATL).