Unsuspected ileal stenosis causing obscure GI bleeding in patients with previous abdominal surgery--diagnosis by capsule endoscopy: a report of two cases

Short article: Negative small-bowel cross-sectional imaging does not exclude capsule retention in high-risk patients

BACKGROUND AND AIMS

Both Agile patency capsule (PC) and small-bowel cross-sectional imaging (SBCSI) techniques have been used to assess small-bowel patency in patients at high risk of capsule retention. The present study aimed to compare capsule retention rates in high-risk patients with negative PC or SBCSI.

MATERIALS AND METHODS

Between January 2011 and December 2013, consecutive patients undergoing small-bowel capsule endoscopy (SBCE) in the Lombardia region were prospectively entered into a dedicated registry. They were classified as being at high or low risk of capsule retention by the local investigator according to predefined clinical criteria. High-risk patients underwent either PC or SBCSI depending on local expertise and availability; those who tested negative underwent SBCE.

RESULTS

Out of 3117 patients (male/female: 1667/1450, mean age: 63.1±17.7), 2942 (94.4%) were classified as being at low risk and 175 (5.6%) were classified as being at high risk for capsule retention. Among 175 high-risk patients, 151 (86.3%) had negative PC and 24 (13.7%) had negative SBCSI: capsule retention occurred in two patients with negative SBCSI (8.3%) and in one patient (0.7%) with negative PC (P=0.049). The capsule retention rates in high-risk patients with negative PC and in low-risk patients (20/2942; 0.7%) were comparable (P=1.0).

CONCLUSION

The capsule retention rate is similar in low-risk and negative PC high-risk patients. Conversely, high-risk patients with negative SBCSI have a significantly higher capsule retention rate. Our data suggest that in high-risk patients, negative SBCSI examination is not reassuring and, when SBCE is indicated, PC should be performed.

Surveillance using capsule endoscopy is safe in post-colectomy patients with familial adenomatous polyposis: a prospective Japanese study

The utility of capsule endoscopy (CE) for the surveillance of small intestinal lesions in familial adenomatous polyposis (FAP) patients has been reported. However, few studies have investigated the safety of CE in FAP patients who have undergone colon surgery. We aimed to assess the safety of surveillance CE in post-colectomy FAP patients and the endoscopic findings associated with small intestinal lesions. We assessed the safety of CE surveillance of small intestinal lesions in 41 FAP patients who had undergone colectomies. Forty-two CEs were performed in 41 patients at our facility from April 2012 to July 2014. CE was conducted safely and none of the capsules were retained, despite the inclusion of patients who had undergone several abdominal surgeries previously. Thirty-nine out of 42 capsules (93 %) were retrieved within the examination timeframe; hence, the retrieval rate was favorable. The findings from this study indicate that surveillance CE can be safely conducted in post-colectomy FAP patients.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

A systematic review.

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

LIMITATIONS

Inclusion and exclusion criteria were loosely defined.

CONCLUSIONS

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

Use of the Given Patency System for the screening of patients at high risk for capsule retention

BACKGROUND

Capsule enteroscopy is a non-invasive diagnostic tool for the study of the small bowel. Due to the risk of capsule retention, capsule enteroscopy is contraindicated in patients with suspected small bowel strictures. The Given Patency Capsule is a disintegration time-controlled capsule developed to identify patients with strictures that may cause capsule enteroscopy retention. The presence of the patency capsule within the patient's body can be detected by a radio-frequency scanner.

AIM OF THE STUDY

To evaluate safety and usefulness of the patency capsule in preventing capsule retention in patients at high risk.

PATIENTS AND METHODS

Thirty-two patients were studied. Indications for patency capsule were: (A) Crohn's disease (18), (B) previous intestinal surgery (7), (C) previous obstruction (1), A+B (3), A+C (1), B+C (2). Patients were evaluated with the scanner at 72 h from ingestion.

RESULTS

At 72 h, 24 patients had already excreted the intact capsule in the stool. Of these, two experienced abdominal pain during capsule passage. In the other eight patients, the scanner detected the presence of the patency capsule. Four of them excreted the capsule intact in the stool after 72-96 h, the remaining four never found the capsule in the stool. The 26 patients who excreted the patency capsule intact without experiencing abdominal pain were deemed eligible for the capsule enteroscopy procedure, which was performed uneventfully in the 25 who agreed to undergo the examination.

CONCLUSIONS

The patency capsule is useful to identify, among patients at high risk, those who can be submitted to capsule enteroscopy without risks of capsule retention.

Contraindications to capsule endoscopy: do any still exist?

In patients requiring WCE most contraindications are relative and the procedure can be performed safely in almost all clinical settings. The only true remaining contraindications to capsule endoscopy are obstruction/pseudo-obstruction and pregnancy. Informed consent of the risks and benefits, including NNE, should be discussed with all patients undergoing WCE examination.

Complications, limitations, and failures of capsule endoscopy: a review of 733 cases

BACKGROUND

Although a variety of technical and clinical problems of capsule endoscopy have been reported, their incidence and clinical importance are unknown. The objective was to evaluate the incidence and the type of such events.

METHODS

This was a retrospective analysis of 733 consecutive examinations at 4 large referral centers. The main outcome measurements were that the problems were classified as "technical," i.e., related to the functioning of the equipment, and "clinical," i.e., related to patient characteristics. For each type of event, the causes and the impact on the ability to reach a diagnosis were examined.

RESULTS

A total of 183 problems were recorded in 174 patients (23.7%): one problem occurred in 165 patients, two in 9 patients. In 8.46% of patients, technical limitations or failures, or clinical complications prevented or hampered diagnosis. Technical problems (e.g., gaps in the recordings, short duration of capsule batteries, failure of downloading) occurred in the early phase of capsule use in 8.6% of examinations and prevented or hampered diagnosis in 2.9%. Clinical problems (difficulty/inability to swallow the capsule, incomplete small-bowel examination) occurred in 16.4% of examinations and hampered or prevented diagnosis in 6.4%. Capsule retention that required surgical or endoscopic retrieval occurred in 1.9% of cases.

CONCLUSIONS

Technical problems were rare and hampered or prevented the diagnosis in a very small number of cases. The majority of clinical failures were related to an incomplete small-bowel examination.

Capsule endoscopy findings in patients with established and suspected small-bowel Crohn's disease: correlation with radiologic, endoscopic, and histologic findings

BACKGROUND

Little is known about the accuracy of capsule endoscopy (CE) in evaluation of small-bowel Crohn's disease.

METHODS

Symptomatic eligible patients had ileocolonoscopy and biopsies from the terminal ileum, followed by small-bowel radiologic studies before CE. Endoscopic, radiologic, CE, and histologic findings were compared. Histology (terminal ileum biopsy specimens or a tissue sample after small-bowel resection) served as a criterion standard.

RESULTS

Fifty-four patients were enrolled; 15 of the 54 patients were excluded from data analysis (critical small-bowel strictures, 14, identified on radiology; incomplete CE, 1). Data were analyzed for 39 patients. All patients had histologic evaluation of the small bowel. Final diagnosis of active small-intestine Crohn's disease was made in 29/39 patients (74.4%). When calculated, CE yielded a sensitivity and a specificity of 89.6% and 100.0%, respectively, and a positive predictive value and a negative predictive value of 100.0% and 76.9%, respectively, whereas small-bowel series were 27.6%/100.0% and 100.0%/32.3%.

CONCLUSIONS

CE is more accurate in detecting small-bowel inflammatory changes suggestive of Crohn's disease than conventional studies. CE, combined with ileocolonoscopy, may be proposed as a first-line investigation of the small intestine in cases of uncomplicated known or suspected Crohn's disease.

Clinical relevance of small-bowel findings detected by wireless capsule endoscopy

OBJECTIVE

Capsule endoscopy is becoming known as a valid tool for identifying sources of obscure gastrointestinal (GI) bleeding. Fewer data are available about its clinical value for other indications.

MATERIAL AND METHODS

Sixty patients (31 F, mean age 47 years, range 14-80 years) with no signs of overt GI bleeding were investigated by Given M2A video capsule for suspected small-bowel disease. The main clinical features were: iron deficient anemia (20), abdominal pain (12), chronic diarrhea (9), malabsorption and weight loss (7), Crohn's disease (CD) (5), and familial adenomatous polyposis (3). Three patients underwent wireless endoscopy for suspected GI neoplasm and one for portal thrombosis.

RESULTS

Complete vision of the small bowel was achieved in 55 patients. No small-bowel lesions were identified in 17 patients, but 5 of them had gastric abnormalities. Small-bowel abnormality was found in 38 patients. Lesions compatible with CD were found in 14 patients, diffuse or patchy enteropathy in 7 and polyps in 6. Actively bleeding lesions were detected in 6 patients and potential bleeding sources in 5. Capsule endoscopy had an overall diagnostic yield of 62%. In particular, three small-bowel malignancies were detected and 9 patients received a better definition of their already-known pathology. However, further endoscopies were needed in 10 patients to obtain a diagnosis. One patient, diagnosed with ileal CD, underwent surgery, as the capsule remained trapped in a stricture.

CONCLUSIONS

Wireless endoscopy effectively visualizes small-bowel abnormalities even though more accurate selection of the patients is needed in order to optimize its diagnostic efficacy.