Wireless capsule endoscopy for evaluation of phenotypic expression of small-bowel polyps in patients with Peutz-Jeghers syndrome and in symptomatic first-degree relatives

Endoscope Capsules: The Present Situation and Future Outlooks

This paper presents new perspectives on photonic technologies for capsule endoscopy. It first presents a review of conventional endoscopy (upper endoscopy and colonoscopy), followed by capsule endoscopy (CE), as well as their techniques, advantages, and drawbacks. The technologies for CEs presented in this paper include integration with the existing endoscopic systems that are commercially available. Such technologies include narrow-band imaging (NBI), photodynamic therapy (PDT), confocal laser endomicroscopy (CLE), optical coherence tomography (OCT), and spectroscopy in order to improve the performance of the gastrointestinal (GI) tract examination. In the context of NBI, two optical filters were designed and fabricated for integration into endoscopic capsules, allowing for the visualization of light centered at the 415 nm and 540 nm wavelengths. These optical filters are based on the principle of Fabry-Perot and were made of thin films of titanium dioxide (TiO2) and silicon dioxide (SiO2). Moreover, strategies and solutions for the adaptation of ECs for PDT are also discussed.

Small Intestinal Polyp Burden in Pediatric Peutz-Jeghers Syndrome Assessed through Capsule Endoscopy: A Longitudinal Study

The management of pediatric Peutz-Jeghers Syndrome (PJS) focuses on the prevention of intussusception complicating small intestinal (SI) polyposis. This hinges on the accurate appraisal of the polyp burden to tailor therapeutic interventions. Video Capsule Endoscopy (VCE) is an established tool to study SI polyps in children, but an in-depth characterization of polyp burden in this population is lacking. Methods: We performed a retrospective longitudinal cross-sectional analysis of VCE studies in pediatric PJS patients at our institution (CMKC) from 2010 to 2020. Demographic, clinical, and VCE findings reported by three reviewers in tandem were accrued. Polyp burden variables were modeled as functions of patient and study characteristics using linear mixed models adjusted for clustering. Results: The cohort included 15 patients. The total small bowel polyp count and largest polyp size clustered under 30 polyps and <20 mm in size. Luminal occlusion correlated closely with the estimated polyp size. Polyp distribution favored proximal (77%) over distal (66%) small bowel involvement. The adjusted largest polyp size was greater in males. Double Balloon Enteroscopy was associated with a decreased polyp burden. Conclusions: The polyp burden in pediatric PJS patients favors the proximal third of the small intestine, with relatively small numbers and a polyp size amenable to resection through enteroscopy. Male gender and older age were related to an increased polyp burden.

Peutz-Jeghers Syndrome and the Role of Imaging: Pathophysiology, Diagnosis, and Associated Cancers

Simple Summary

The Peutz-Jeghers Syndrome is a rare autosomal dominant syndrome characterized by mucocutaneous pigmentations, multiple gastrointestinal hamartomatous polyps, and an elevated risk of malignancy. Awareness of various Peutz-Jeghers Syndrome imaging patterns, associated malignancies, and their complications is crucial for accurate imaging interpretation and patient management. In this manuscript, we provide an overview of this condition, associated malignancies, and imaging surveillance protocols.

Abstract

The Peutz-Jeghers Syndrome (PJS) is an autosomal dominant neoplastic syndrome defined by hamartomatous polyps through the gastrointestinal tract, development of characteristic mucocutaneous pigmentations, and an elevated lifetime cancer risk. The majority of cases are due to a mutation in the STK11 gene located at 19p13.3. The estimated incidence of PJS ranges from 1:50,000 to 1:200,000. PJS carries an elevated risk of malignancies including gastrointestinal, breast, lung, and genitourinary (GU) neoplasms. Patients with PJS are at a 15- to 18-fold increased malignancy risk relative to the general population. Radiologists have an integral role in the diagnosis of these patients. Various imaging modalities are used to screen for malignancies and complications associated with PJS. Awareness of various PJS imaging patterns, associated malignancies, and their complications is crucial for accurate imaging interpretation and patient management. In this manuscript, we provide a comprehensive overview of PJS, associated malignancies, and surveillance protocols.

Pathogenesis, diagnosis, and treatment of Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS), an autosomal dominant inherited disease, is caused by germinal mutations of the STK11. It is characterized by gastrointestinal hamartomas, mucocutaneous pigmentation and increased cancer risk. Germline mutations in STK11 cause a harmful effect on cell apoptosis, G1 arrest, and cell polarization, which leads to polyp formation and cancer occurrence. Balloon-assisted enteroscopy is widely used in removal of PJS polyps in the small bowel and it is proved to be safe and effective. We suggest to screen polyps and cancer in PJS patients, which seems to benefit these patients in the long run.

Management of Peutz-Jeghers Syndrome in Children and Adolescents: A Position Paper From the ESPGHAN Polyposis Working Group

Peutz-Jeghers syndrome (PJS) is a well-described inherited syndrome, characterized by the development of gastrointestinal polyps, and characteristic mucocutaneous freckling. Development of small bowel intestinal polyps may lead to intussusception in children may require emergency laparotomy with potential loss of bowel. Gastrointestinal polyps may lead to bleeding and anemia. This European Society for Paediatric Gastroenterology Hepatology and Nutrition position paper provides a guide for diagnosis, assessment, and management of PJS in children and adolescents and guidance on avoiding complications from PJS or from the endoscopic procedures performed on these patients.This is the first position paper regarding PJS published by European Society for Paediatric Gastroenterology Hepatology and Nutrition. Literature from PubMed, Medline, and Embase was reviewed and in the absence of evidence, recommendations reflect the opinion of pediatric and adult experts involved in the care of polyposis syndromes. Because many of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, some of the recommendations are based on expert opinion. This position paper will be helpful in the appropriate management and timing of procedures in children and adolescents with PJS.

Small-bowel Surveillance in Patients With Peutz-Jeghers Syndrome: Comparing Magnetic Resonance Enteroclysis and Double Balloon Enteroscopy

BACKGROUND AND STUDY AIMS

Small-bowel surveillance with polypectomy of polyps ≥15 mm prevents complications in patients with Peutz-Jeghers syndrome (PJS). We aimed to compare magnetic resonance enteroclysis (MRE) and double balloon enteroscopy (DBE) for diagnostic yield of these polyps and for patient preference.

MATERIALS AND METHODS

PJS patients prospectively underwent MRE followed by proximal DBE within 20 weeks. Endoscopists were blinded to the MRE results. We compared number of polyps ≥15 mm detected by MRE and DBE. Patients' perceptions of both procedures were assessed using questionnaires.

RESULTS

Fifteen PJS patients (67% males, median age 47 y) underwent both MRE and DBE. Polyps ≥15 mm were identified by MRE and/or DBE in 12/15 (80%) patients. There was no significant difference in the detection of polyps ≥15 mm (38 by MRE vs. 50 by DBE, P=0.37). Sensitivity for these polyps was 62% (38/61) for MRE and 82% (50/61) for DBE. Patients' perceived shame and burden did not differ significantly between MRE and DBE. Patients reported significantly more pain during preparation for MRE than for DBE (moderate vs. no pain, P=0.02), although perceived pain during the procedures was comparable (both mild, P=0.89). For future small-bowel surveillance 10/13 (77%) patients preferred DBE over MRE (P=0.09).

CONCLUSIONS

Our results suggest that MRE and DBE have a comparable diagnostic yield of polyps ≥15 mm. However, DBE allows for direct intervention and was preferred over MRE by most patients in this series. Larger cohorts of PJS patients are needed to fully evaluate the diagnostic yield of DBE compared with other modalities.

Multicenter survey on the use of device-assisted enteroscopy in Portugal

BACKGROUND

Device-assisted enteroscopies (DAEs) are recent endoscopic techniques that enable direct endoscopic small-bowel evaluation.

OBJECTIVE

The objective of this article is to evaluate the implementation of DAEs in Portugal and assess the main indications, diagnoses, diagnostic yield, therapeutic yield and complication rate.

METHODS

We conducted a multicenter retrospective series using a national Web-based survey on behalf of the Portuguese Small-Bowel Study Group. Participants were asked to fill out two online databases regarding procedural data, indications, diagnoses, endoscopic therapy and complications using prospectively collected institutional data records.

RESULTS

A total of eight centers were enrolled in the survey, corresponding to 1411 DAEs. The most frequent indications were obscure gastrointestinal bleeding (OGIB), inflammatory bowel disease and small-bowel tumors. The pooled diagnostic yield was 63%. A relation between the diagnostic yield and the indications was clear, with a diagnostic yield for OGIB of 69% (p = 0.02) with a 52% therapeutic yield. Complications occurred in 1.2%, with a major complication rate of 0.57%. Perforations occurred in four patients (0.28%).

CONCLUSION

DAEs are safe and effective procedures, with complication rates of 1.2%, the most serious of which is perforation. Most procedures are performed in the setting of OGIB. Diagnostic and therapeutic yields are dependent on the indication, hence appropriate patient selection is crucial.

Contrast-Enhanced Cross Sectional Imaging and Capsule Endoscopy: New Perspectives for a Whole Picture of the Small Bowel

Small bowel evaluation is a challenging task and has been revolutionized by high-quality contrasted sectional imaging (CT enterography - CTE) and magnetic resonance enterography (MRE) as well as by small bowel capsule endoscopy (SBCE). The decision of which technique to employ during the investigation of small bowel diseases is not always simple or straightforward. Moreover, contraindications may preclude the use of these techniques in some patients, and although they are noninvasive procedures, may present with various complications. SBCE plays a crucial role in the investigation of both obscure gastrointestinal bleeding and Crohn's disease, but it is also useful for surveillance of patients with Peutz-Jeghers syndrome, while CTE is very accurate in small bowel tumours and in established Crohn's Disease, and its use in patients presenting with gastrointestinal bleeding is increasing. MRE, an expensive and not widely available technique, is essential for the study of patients with Crohn's Disease, and presents an attractive alternative to SBCE in Peutz-Jeghers syndrome surveillance. These diagnostic modalities are often not competitive but synergistic techniques. Knowing their characteristics, strengths and limitations, indications, contraindications and potential complications, as well as the adaptation to local availability and expertise, is essential to better select which procedures to perform in each patient, both safely and effectively, in order to optimize management and improve patient outcomes.

The Importance of Alternative Diagnostic Modalities in the Diagnosis of Small Bowel Tumors After a Negative Capsule Endoscopy

Capsule endoscopy is widely accepted as the preferred diagnostic test in the evaluation of small bowel diseases, especially in the setting of obscure gastrointestinal bleeding. It has revolutionized small bowel examination and has improved the detection of small bowel tumors. However, small bowel tumors are sometimes missed by capsule endoscopy. Furthermore, there are several recent reports comparing capsule endoscopy with other diagnostic modalities, such as double balloon enteroscopy and CT/RM enterography, that challenge the reportedly high negative predictive value of capsule endoscopy in detecting small bowel tumors. We report the case of a patient with overt obscure gastrointestinal bleeding due to a gastrointestinal stromal tumor diagnosed by CT enterography after two negatives capsule endoscopies. This case shows that capsule endoscopy may overlook significant life threatening lesions and highlights the importance of using other diagnostic modalities after a negative capsule endoscopy, especially in patients with a high index of suspicion for small bowel tumoral pathology or persistent/recurrent bleeding.

Update on imaging of Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant disease linked to a mutation of the STK 11 gene and is characterized by the development of benign hamartomatous polyps in the gastrointestinal tract in association with a hyperpigmentation on the lips and oral mucosa. Patients affected by PJS have an increased risk of developing gastrointestinal and extra-digestive cancer. Malignancy most commonly occurs in the small-bowel. Extra-intestinal malignancies are mostly breast cancer and gynecological tumors or, to a lesser extent, pancreatic cancer. These polyps are also at risk of acute gastrointestinal bleeding, intussusception and bowel obstruction. Recent guidelines recommend regular small-bowel surveillance to reduce these risks associated with PJS. Small-bowel surveillance allows for the detection of large polyps and the further referral of selected PJS patients for endoscopic enteroscopy or surgery. Video capsule endoscopy, double balloon pushed enteroscopy, multidetector computed tomography and magnetic resonance enteroclysis or enterography, all of which are relatively new techniques, have an important role in the management of patients suffering from PJS. This review illustrates the pathological, clinical and imaging features of small-bowel abnormalities as well as the role and performance of the most recent imaging modalities for the detection and follow-up of PJS patients.

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.

Contribution of capsule endoscopy to Peutz-Jeghers syndrome management in children

BACKGROUND

Capsule endoscopy is recommended for children with Peutz-Jeghers syndrome as young as 8 years of age. Aim of our study was to evaluate the contribution of capsule endoscopy in managing risk of further obstructive complications.

METHODS

A retrospective analysis of 27 children who received at least 1 capsule endoscopy was conducted. Peutz-Jeghers syndrome was diagnosed based on the presence of an STK11 gene mutation or on the association of a hamartoma with 2 of 3 criteria (family history, mucocutaneous pigmentation, small bowel polyposis).

RESULTS

Thirty-seven capsule endoscopies were performed in 27 patients. The median age at first endoscopy was 11.4 years (range, 5.4-20.9). Jejunal polyps were found in 72% and ileal polyps in 55% of capsules. The original recommendations were followed 20/30 times. Three gastroscopies, 4 colonoscopies, 7 double balloon enteroscopies and 1 intra-operative enteroscopy were performed after the capsules. These procedures revealed jejunal polyps in 9/9 cases (8/9 resected) and ileal polyps in 3/5 (all resected). One intussusception occurred 8.4 months after the capsule endoscopy and required surgical resection.

CONCLUSION

Capsule endoscopy is easily feasible in Peutz Jeghers syndrome, but the practice of systematic and repeated procedures needs to be validated prospectively.

Inpatient capsule endoscopy leads to frequent incomplete small bowel examinations

AIM: To examine the predictive factors of capsule endoscopy (CE) completion rate (CECR) including the effect of inpatient and outpatient status.

METHODS: We identified 355 consecutive patients who completed CE at Rush University Medical Center between March 2003 and October 2005. Subjects for CE had either nothing by mouth or clear liquids for the afternoon and evening of the day before the procedure. CE exams were reviewed by two physicians who were unaware of the study hypotheses. After retrospective analysis, 21 cases were excluded due to capsule malfunction, prior gastric surgery, endoscopic capsule placement or insufficient data. Of the remaining 334 exams [264 out-patient (OP), 70 in-patient (IP)], CE indications, findings, location of the patients [IP vs OP and intensive care unit (ICU) vs general medical floor (GMF)] and gastrointestinal transit times were analyzed. Statistical analysis was completed using SPSS version 17 (Chicago, IL). Chi-square, t test or fisher exact-tests were used as appropriate. Multivariate logistic regression analysis was used to identify variables associated with incomplete CE exams.

RESULTS: The mean age for the entire study population was 54.7 years. Sixty-one percent of the study population was female, and gender was not different between IPs vs OPs (P = 0.07). The overall incomplete CECR was 14% in our study. Overt obscure gastrointestinal bleeding (OGB) was a significantly more common indication for the IP CE (P = 0.0001), while abdominal pain and assessment of IBD were more frequent indications for the OP CE exams (P = 0.002 and P = 0.01, respectively). Occult OGB was the most common indication and arteriovenous malformations were the most common finding both in the IPs and OPs. The capsule did not enter the small bowel (SB) in 6/70 IPs and 8/264 OPs (P = 0.04). The capsule never reached the cecum in 31.4% (22/70) of IP vs 9.5% (25/ 264) of OP examinations (P < 0.001). The mean gastric transit time (GTT) was delayed in IPs compared to OPs, 98.5 ± 139.5 min vs 60.4 ± 92.6 min (P = 0.008). Minimal SB transit time was significantly prolonged in the IP compared to the OP setting [IP = 275.1 ± 111.6 min vs OP = 244.0 ± 104.3 min (P = 0.037)]. CECR was also significantly higher in the subgroup of patients with OGB who had OP vs IP exams (95% vs 80% respectively, P = 0.001). The proportion of patients with incomplete exams was higher in the ICU (n = 7/13, 54%) as compared to the GMF (n = 15/57, 26%) (P = 0.05). There was only a single permanent SB retention case which was secondary to a previously unknown SB stricture, and the remaining incomplete SB exams were due to slow transit. Medications which affect gastrointestinal system motility were tested both individually and also in aggregate in univariate analysis in hospitalized patients (ICU and GMF) and were not predictive of incomplete capsule passage (P > 0.05). Patient location (IP vs OP) and GTT were independent predictors of incomplete CE exams (P < 0.001 and P = 0.008, respectively).

CONCLUSION: Incomplete CE is a multifactorial problem. Patient location and related factors such as severity of illness and sedentary status may contribute to incomplete exams.

Small bowel endoscopy in children

Endoscopic investigation of small bowel pathology in children has historically been difficult due to location, length and tortuosity of the small bowel. Recently, video capsule endoscopy and balloon-assisted enteroscopy techniques have evolved as new diagnostic tools and are increasingly used in the paediatric population. In this review the current literature is appraised to define the clinical indications and practical aspects of capsule endoscopy and balloon-assisted enteroscopy in children.

Small bowel endoscopy and Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant inherited disease. It is clinically characterized by the development of gastrointestinal hamartomas, mainly located in the small bowel. These hamartomas are prone to complications such as intussusceptions, abdominal complaints and anaemia. Furthermore, patients are at increased risk for developing small bowel cancer. Therefore, regular surveillance of the small bowel is indicated. However, the optimal strategy for surveillance has not been determined yet. This review gives an overview of the different techniques that have been described to examine the small bowel of PJS patients. First, a number of radiologic and endoscopic imaging modalities with diagnostic value are discussed. Secondly, recently developed advanced endoscopy techniques are described that can serve both as a diagnostic and therapeutic tool in the surveillance of the small bowel. Finally, a recommendation is given how to apply these individual techniques for small bowel surveillance in a step-up approach.

Outcome of patients who have undergone total enteroscopy for obscure gastrointestinal bleeding

AIM: To assess the diagnostic success and outcome among patients with obscure gastrointestinal bleeding who underwent total enteroscopy with double-balloon endoscopy.

METHODS: Total enteroscopy was attempted in 156 patients between August 2003 and June 2008 at Hiroshima University Hospital and achieved in 75 (48.1%). It is assessed whether sources of bleeding were identified, treatment methods, complications, and 1-year outcomes (including re-bleeding) after treatment, and we compared re-bleeding rates among patients.

RESULTS: The source of small bowel bleeding was identified in 36 (48.0%) of the 75 total enteroscopy patients; the source was outside the small bowel in 11 patients (14.7%) and not identified in 28 patients (37.3%). Sixty-one of the 75 patients were followed up for more than 1 year (27.2 ± 13.3 mo). Four (6.6%) of these patients showed signs of re-bleeding during the first year, but bleeding did not recur after treatment. Although statistical significance was not reached, a marked difference was found in the re-bleeding rate between patients in whom total enteroscopy findings were positive (8.6%, 3/35) and negative (3.8%, 1/26) (3/35 vs 1/26, P = 0.63).

CONCLUSION: A good outcome can be expected for patients who undergo total enteroscopy and receive proper treatment for the source of bleeding in the small bowel.

Gastric tumours in hereditary cancer syndromes: clinical features, molecular biology and strategies for prevention

Gastric cancer is the major cause of cancer-related deaths worldwide. The majority of them are classified as sporadic, whereas the remaining 10% exhibit familial clustering. Hereditary diffuse gastric cancer (HDGC) syndrome is the most important condition that leads to hereditary gastric cancer. However, other hereditary cancer syndromes, such as hereditary non-polyposis colorectal cancer, familial adenomatous polyposis, Peutz-Jeghers syndrome, Li-Fraumeni syndrome and hereditary breast and ovarian cancer, entail a higher risk compared to the general population for developing this kind of neoplasia. In this review, we describe briefly the most important aspects related to clinical features, molecular biology and strategies for prevention in hereditary gastric associated to different cancer syndromes.

CT-enterography may identify small bowel tumors not detected by capsule endoscopy: eight years experience at Mayo Clinic Rochester

BACKGROUND

Capsule endoscopy (CE) is widely accepted as the preferred diagnostic test in the evaluation of small bowel diseases. However, small bowel tumors (SBT) are sometimes missed by CE. Preliminary studies suggest that CT-enterography (CTE) may play a role in detecting SBT.

AIMS

The purpose of this study was to compare the performance of CE and CTE in detecting SBT METHODS: This was a single center, retrospective study. Patients treated at the Mayo Clinic Rochester between January 2000 and December 2008 with a discharge diagnosis of SBT and negative initial esophagogastroduodenoscopy (EGD) and colonoscopy were identified through a search of the electronic medical records. Among 103 identified patients, 41 had undergone CE, CTE or both, and comprised our study group. The exact binomial sensitivity of CE and CTE in detecting SBT was calculated. Demographic characteristics, clinical presentation, results of diagnostic tests, and tumor characteristics were recorded for each patient.

RESULTS

CTE and CE detected 38/41 (sensitivity 92.7%; 95% CI 80.1-98.5) and 8/27 (sensitivity 29.6%; 95% CI 13.8-50.2) of the SBT identified at Mayo Clinic Rochester, respectively. Seventeen patients had both CTE and CE. In this subgroup of patients, CTE detected SBT in 16/17 (sensitivity 94.1; 95% CI 72.7-99.9) and CE in 6/17 (sensitivity 35.3%; 95% CI 13.3-59). The matched paired difference in the sensitivity of two techniques in detecting SBT was statistically significant (P = 0.004).

CONCLUSION

CTE may identify SBT not diagnosed by CE.

Balloon-assisted enteroscopy with prophylactic polypectomy for Peutz-Jeghers syndrome: experience in Taiwan

BACKGROUND

Peutz-Jeghers syndrome (PJS) is a very rare disease that often causes severe complications such as bowel obstruction or gastrointestinal tract bleeding. In the past, it was usually treated by using surgical intervention despite the associated complications. Balloon-assisted enteroscopy (BAE) has been documented as an effective and safe method for the diagnosis and treatment of small bowel lesions. Hence, we conducted this study to verify whether BAE is useful for patients with PJS.

AIM

To evaluate the safety and efficacy of BAE with prophylactic polypectomy in patients with PJS.

METHODS AND PATIENTS

From August 2005 to February 2010, 6 consecutive patients were diagnosed with PJS after pathological and clinical examination, and underwent BAE examination and polypectomy at Chang Gung Memorial Hospital, an academic tertiary referral center.

RESULTS

Six consecutive patients (4 men and 2 women) diagnosed with PJS underwent BAE with polypectomy. BAE was performed 17 times for complete examination of the entire small bowel. The range of the diameter of the removed polyps was 1-6 cm. No immediate complications such as hemorrhage or hollow organ perforation were noted during the procedure, and no patient developed intussusception during the follow-up period (32 ± 17.5 months).

CONCLUSION

BAE with polypectomy is useful for patients with PJS in order to reduce the complications of the condition.

The association of adrenocortical carcinoma and thyroid cancer in a child with Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is a rare, dominantly inherited disorder characterized by gastrointestinal hamartomatous polyps, mucocutaneous hyperpigmentation, and an increased risk of cancer. We present a 16-month-old child diagnosed with PJS, who had distinguishing features compared with the previously reported cases with respect to her clinical presentation, associated malignancies, and genetic analysis. To our knowledge, this is the first report of adrenocortical carcinoma in association with PJS, as well as the first instance of associated thyroid cancer in a child with PJS. We briefly review the relevant literature and highlight the recent progress achieved in the investigation of the syndrome.

Can capsule endoscopy be used as a diagnostic tool in the evaluation of nonbleeding indications in daily clinical practice? A prospective study

OBJECTIVE

To evaluate the diagnostic yield of capsule endoscopy (CE) and its impact on treatment and outcome in patients without bleeding indications.

SUBJECTS AND METHODS

One hundred and sixty-five nonbleeding patients were enrolled in the study. The most common indications for CE were chronic abdominal pain alone (33 patients) or combined with chronic diarrhea (31 patients) and chronic diarrhea alone (30 patients). Among the 165 patients, 129 underwent CE for evaluation of gastrointestinal symptoms and 36 for surveillance or disease staging.

RESULTS

CE findings were positive, suspicious and negative in 73 (44.2%), 13 (7.9%) and 79 (47.9%) of cases, respectively. The diagnostic yield was highest in patients with refractory celiac disease (10/10, 100%) and suspected Crohn's disease (5/6, 83.3%), followed by patients with chronic abdominal pain and chronic diarrhea (13/31, 41.9%), established Crohn's disease (2/6, 33.3%), chronic diarrhea alone (8/30, 26.7%), chronic abdominal pain alone (8/33, 24.2%) and other indications (3/13, 23.1%) (p < 0.005). The CE findings led to a change of medication in 74 (47.7%) patients, surgery in 15 (9.7%), administration of a strict gluten-free or other special diet in 13 (8.4%) and had other consequences in 11 (6.7%). Management was not modified in 42 (27.1%) patients. Among symptomatic patients (n = 129), 29 (22.5%) were lost to follow-up. The remaining 100 patients were followed up for 8.7 ± 4.0 months (range 2-19). Among the latter, resolution or improvement of symptoms was observed in 86 (86%) patients, no change in 11 (11%) and 3 (3%) died. All 86 patients who experienced resolution or improvement of their symptoms had a modification of their management after CE; only 7/11 patients whose symptoms did not change (63.6%) and 2/3 patients who died (66.7%) had a modification of management (p < 0.001).

CONCLUSIONS

CE appears to be a useful tool in the evaluation of patients with nonbleeding indications. The outcome of most patients with negative findings was excellent.

Capsule endoscopy in small-bowel surveillance of patients with hereditary polyposis syndromes

PURPOSE

Familial adenomatous polyposis (FAP) and Peutz-Jeghers syndrome (PJS) are hereditary polyposis syndromes with a high risk for benign small-bowel polyps and cancer. The aim of this study was to assess the prevalence of small-bowel polyps beyond the duodenum in patients with FAP and PJS and to examine the clinical value and the optimal interval of capsule endoscopy (CE) for the surveillance of small-bowel polyps in patients with FAP.

METHODS

Between 2002 and 2009, standard gastroscopy, duodenoscopy, and CE were performed on 19 consecutive patients with hereditary polyposis syndromes (FAP n=15; PJS n=4). The number, size, and location of polyps detected by CE were assessed. Five FAP patients had repeated CEs in intervals of 2-7 years.

RESULTS

In 13 of the 15 (87%) FAP patients, small-bowel polyps were detected by CE ranging from estimated <5 mm to >10 mm in size. Thereof, in four patients, medium-sized (5-10 mm) or large-sized (>10 mm) polyps were seen-all of them located in the proximal jejunum. In three FAP patients with repeated CEs, the latest CE displayed medium- and large-sized polyps in the proximal jejunum, whereas previous CEs had detected only small-sized (<5 mm) polyps. In three of the four PJS patients, large-sized small-bowel polyps were visualized by CE which could then be removed by double-balloon enteroscopy (DBE) or surgical resection.

CONCLUSION

CE is an effective and safe method for small-bowel surveillance in FAP and PJS.

A prospective study of MR enterography versus capsule endoscopy for the surveillance of adult patients with Peutz-Jeghers syndrome

OBJECTIVE

The objective of our study was to assess the utility of MR enterography compared with capsule endoscopy for the detection of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS).

SUBJECTS AND METHODS

Adult patients with PJS scheduled for surveillance capsule endoscopy were prospectively recruited and underwent MR enterography and capsule endoscopy. Polyps > 10 mm were regarded as clinically relevant. When appropriate, large polyps (> 15 mm) were removed at enteroscopy, enabling correlation with MR enterography and capsule endoscopy findings. Interobserver agreement for MR enterography and capsule endoscopy was calculated. Patient comfort, convenience, and test preference were assessed.

RESULTS

Nineteen patients (median age, 39.6 years) underwent both procedures. There was no significant difference between techniques for the detection of polyps > 10 mm (18 vs 23 polyps at capsule endoscopy and MR enterography, respectively; p = 0.35) or in the number of patients in whom > 10 mm polyps were detected (eight vs 11 patients at capsule endoscopy and MR enterography, respectively; p = 0.38). However, in three patients, large polyps (> 15 mm) detected on MR enterography were not detected on capsule endoscopy; large polyps were seen in six patients at capsule endoscopy and in nine patients at MR enterography (p = 0.25). Interobserver agreement was high for MR enterography but was only fair for capsule endoscopy (kappa = 0.81 and 0.27, respectively). Size assessments of large polyps (> 15 mm) appeared more reproducible with MR enterography than with capsule endoscopy. Patients rated capsule endoscopy as more comfortable than MR enterography. There was no significant difference between the techniques with regard to patient convenience or preference.

CONCLUSION

MR enterography is a promising alternative to capsule endoscopy for small-bowel surveillance in adults with PJS. Although our results suggest that capsule endoscopy is more comfortable for the patient, MR enterography may be less prone to missing large polyps and may be more reliable in their size assessment.

Endoscopic therapy of small-bowel polyps by double-balloon enteroscopy in patients with Peutz-Jeghers syndrome

BACKGROUND

Peutz-Jeghers syndrome (PJS) is a hereditary disorder characterized by mucocutaneous pigmentations and hamartomatous polyps mainly in the small bowel. These polyps may cause complications such as intussusception.

OBJECTIVE

To assess therapeutic efficacy and safety of double-balloon enteroscopy (DBE) for detection and treatment of small-bowel polyps in patients with PJS.

DESIGN

Prospective cohort study.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved 13 patients with PJS, defined as a proven STK11 gene mutation or according to international diagnostic criteria.

INTERVENTION

DBE with enteroscopic removal of pedunculated polyps of > or =10 mm.

MAIN OUTCOME MEASUREMENTS

Location, number and size of small-bowel polyps, polypectomy data, and complications and long-term complications associated with development of small-intestine polyps.

RESULTS

Thirteen patients with PJS (8 male, mean age 31 years) underwent 29 DBE procedures. Ten patients (77%) had a history of partial small-bowel resection because of small-bowel polyps. Small-bowel polyps were found in all 13 patients. The majority of polyps (94%) were located in the proximal jejunum. A total of 82 polyps of > or =10 mm were detected, and 79 (96%) were endoscopically removed without complications. After the introduction of DBE, no small-intestine-polyp-related complications occurred during a follow-up period of 356 person-months.

LIMITATIONS

Small number of patients.

CONCLUSION

DBE is clinically useful and safe for diagnosis and therapy of small-bowel polyps in patients with PJS, even in patients with a history of extensive abdominal surgery. DBE may decrease the need for laparotomy in patients with PJS.

Capsule retention: a feared complication of wireless capsule endoscopy

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

Comparison of intraoperative enteroscopy and double-balloon enteroscopy for the diagnosis and treatment of Peutz-Jeghers syndrome

BACKGROUND

Double-balloon enteroscopy (DBE) is an enteroscopy method that allows examination and treatment of the small bowel. Intraoperative enteroscopy (IOE) was the only possibility of endoscopic treatment for patients with Peutz-Jeghers syndrome (PJS) before the DBE era. PJS is an inherited, autosomal dominant disorder distinguished by hamartomatous polyps in the gastrointestinal tract and pigmented mucocutaneous lesions. PJS predisposes sufferers to various malignancies. Bleeding, obstruction, and intussusception are common complications in patients with PJS. The goal of this study was compare our experience in diagnosis and treatment of small-bowel hamartomas by means of DBE and IOE.

METHODS

From 1999 to 2006, we performed seven IOEs in seven patients (four women, three men), and since 2006, 14 DBEs in another ten patients (seven women, three men).

RESULTS

A total of 182 polyps were removed during IOEs: 179 by the endoscopist and three were cut out by the surgeon. From 6 to 75 polyps were removed per session (mean, 26). The largest hamartoma measured 4 cm in diameter. The age of the patients ranged from 20 to 50 (mean, 31) years. In our DBE group, a total of 205 polyps were removed. From 1 to 37 polyps were removed per session (mean, 13). The age of the patients ranged from 12 to 48 (mean, 25) years. The largest hamartoma was 6 cm in diameter. We had no serious complications both in the IOE and the DBE group.

CONCLUSIONS

Polypectomy using DBE may obviate the need for repeated urgent operations and small-bowel resections leading to short-bowel syndrome. Patients are indicated for prophylactic procedure and polypectomy of the entire small bowel. Both DBE and IOE facilitate exploration and treatment of the small intestine. DBE is less invasive and more convenient for the patient. Both procedures are generally safe and useful.

Peutz-Jeghers syndrome: Diagnostic and therapeutic approach

Peutz-Jeghers syndrome (PJS) is an inherited, autosomal dominant disorder distinguished by hamartomatous polyps in the gastrointestinal tract and pigmented mucocutaneous lesions. Prevalence of PJS is estimated from 1 in 8300 to 1 in 280 000 individuals. PJS predisposes sufferers to various malignancies (gastrointestinal, pancreatic, lung, breast, uterine, ovarian and testicular tumors). Bleeding, obstruction and intussusception are common complications in patients with PJS. Double balloon enteroscopy (DBE) allows examination and treatment of the small bowel. Polypectomy using DBE may obviate the need for repeated urgent operations and small bowel resection that leads to short bowel syndrome. Prophylaxis and polypectomy of the entire small bowel is the gold standard in PJS patients. Intraoperative enteroscopy (IOE) was the only possibility for endoscopic treatment of patients with PJS before the DBE era. Both DBE and IOE facilitate exploration and treatment of the small intestine. DBE is less invasive and more convenient for the patient. Both procedures are generally safe and useful. An overall recommendation for PJS patients includes not only gastrointestinal multiple polyp resolution, but also regular lifelong cancer screening (colonoscopy, upper endoscopy, computed tomography, magnetic resonance imaging or ultrasound of the pancreas, chest X-ray, mammography and pelvic examination with ultrasound in women, and testicular examination in men). Although the incidence of PJS is low, it is important for clinicians to recognize these disorders to prevent morbidity and mortality in these patients, and to perform presymptomatic testing in the first-degree relatives of PJS patients.

Feasibility of video capsule endoscopy in the management of children with Peutz-Jeghers syndrome: a blinded comparison with barium enterography for the detection of small bowel polyps

OBJECTIVES

Peutz-Jeghers syndrome (PJS) in children may present with anaemia, intussusception, or obstruction from an early age and surgery is common. Prophylactic polypectomy may reduce subsequent complications. Traditional barium enterography (BE) has poor sensitivity and requires significant radiation. We compared the performance of capsule endoscopy (CE) with BE in children with PJS.

MATERIALS AND METHODS

Children with PJS (ages 6.0-16.5 years) were prospectively recruited and underwent BE followed by CE, each reported by expert reviewers blinded to the alternate modality. Number of "significant" (>10 mm) and total number of polyps were recorded. Child preference was assessed using a visual analogue questionnaire. Definitive findings were assessed at laparotomy or enteroscopy, when performed.

RESULTS

There was no significant difference for >10 mm polyp detection. Six polyps were found in 3 children by both modalities: 3 polyps in 2 children at CE, 3 polyps in 1 child at BE (P=0.50). Re-review of 1 CE identified 3 polyps that were missed in 1 child at initial reading. Significantly more <10 mm polyps were identified by CE than BE: 61 vs 6 (P=0.02). CE was significantly more comfortable than BE (median score CE 76 [interquartile range 69-87] vs BE 37 [interquartile range 31-68], P=0.03) and was the preferred investigation in 90% (P=0.02).

CONCLUSIONS

CE is a feasible, safe, and sensitive test for small bowel polyp surveillance in children with PJS. It is significantly more comfortable than BE and is the preferred test of most children for future surveillance. There is a learning curve for reporting CE studies in PJS and appropriate training is essential.

Computer-aided learning in capsule endoscopy leads to improvement in lesion recognition ability

BACKGROUND

The rapid expansion in use of capsule endoscopy (CE) has led to discussion about training needs and provision. The lesion recognition skills required for CE are ideally suited to computer-based training.

OBJECTIVE

The aim of this study was to prospectively evaluate the educational effectiveness of a computer-based CE training and testing module on trainees with varying experience.

DESIGN

This was a prospective educational evaluation study.

SETTING

Academic endoscopy unit.

PATIENTS

This study involved 28 trainees of varying CE experience (medical students, gastroenterology trainees) and 4 CE experts.

INTERVENTION

Trainees (medical students and gastroenterology trainees) without CE experience completed a 60-question, computer-based test module consisting of 30-second video clips and multiple-choice questions. Without feedback, trainees then completed a comprehensive, menu-driven, computer-based CE training module. The test module was then completed a second time and feedback was given. Expert performance on the test module was benchmarked by 4 CE experts.

MAIN OUTCOME MEASUREMENTS

The first measure was the difference in baseline performance on the test module between trainees and experts (to determine construct validity). The second measure was a change in performance on the test module after training (to determine content validity of the training module).

RESULTS

A significant difference was noted in baseline performance (P < .001) among CE experts (mean 73.8% +/- 8.0%), gastroenterology trainees (49.5% +/- 10.9%), and medical students (29.5% +/- 3.3%). Performance improved significantly (P < .001) in both trainee groups after training (gastroenterology trainees' posttraining score 62.1% +/- 7.7%; medical students' 46.7% +/- 6.8%).

CONCLUSION

Computer-based learning has a potentially significant role in the development of a training syllabus for CE and in CE accreditation.

Follow-up and surgical management of Peutz-Jeghers syndrome in children

BACKGROUND

Peutz-Jeghers syndrome (PJS) is an autosomal dominant syndrome with an increased risk of polyposis complications and intestinal and extraintestinal tumours.

METHODS

During the last 15 years, we reviewed a series of 11 children with PJS, with special attention to evolution and follow-up. Diagnosis was based on at least 1 hamartomatous polyp associated with 2 of the 3 following criteria: family record of PJS, polyposis localised on small bowel, and mucocutaneous pigmentation. Diagnosis of PJS also could be raised by a single genetic analysis of STK11 gene.

RESULTS

Median age at beginning of symptoms was 6 years old. Seven of the 11 children had genetic tests, which were positive for STK11 gene mutation. Among the 10 children presenting with gastrointestinal complications, 8 were operated on, 6 had at least 1 small bowel resection, and 4 had repeat surgery for recurrent intussusceptions. In case of complications leading to a surgical procedure, we performed intraoperative enteroscopy to remove all large polyps. To prevent any polyposis complications, we suggest a complete check-up of polyposis topography with some of the new endoscopic tools, either double-balloon endoscopy or videocapsule endoscopy.

CONCLUSIONS

Children with PJS have a high risk of numerous laparotomies due to polyps' complications. Therefore, a screening of intestinal polyposis by videocapsule endoscopy is recommended, as well as a screening of the most frequent sites of cancers for the patient's whole life. During any abdominal procedure, they should have an intraoperative endoscopy, this management allowing an increased time interval between 2 laparotomies.

Hamartomatous polyposis syndromes

Hamartomatous polyposis syndromes are a diverse group of inherited conditions grouped together because they exhibit hamartomatous rather than epithelial polyp histology. Each syndrome exhibits characteristic polyp histology, gastrointestinal polyp distribution, gastrointestinal cancer risks, extra-intestinal benign findings and often extra-intestinal cancer risks. Identifying individuals at risk for these syndromes and accurately defining the precise diagnosis are necessary for planning surveillance and management in order to prevent the benign and malignant complications. Characteristic syndrome features including gastrointestinal findings, pathology, genetics, and management options for the three most common hamartomatous polyposis syndromes, Peutz-Jeghers syndrome, PTEN hamartoma tumour syndrome, and juvenile polyposis will be presented in this review.

Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy

BACKGROUND

Capsule endoscopy (CE) is considered a first-line investigation for obscure GI bleeding (OGIB) and small-bowel polyp or tumor detection. The reliability of a negative CE in excluding gross small-bowel pathology remains unclear. New imaging modalities, such as double-balloon enteroscopy (DBE), CT enterography (CTE) or magnetic resonance enterography (MRE) now provide complementary roles to CE for these indications.

OBJECTIVE

We describe our experience of significant small-bowel pathology missed at CE in 5 patients. The lesions were subsequently detected by DBE, CTE, or MRE.

DESIGN

A retrospective case series.

SETTING

Single-center academic endoscopy unit in a tertiary-referral hospital.

PATIENTS

Five patients were evaluated: 4 with a history of OGIB (transfusion dependent in 2) and 1 patient with Peutz-Jeghers syndrome (PJS) under small-bowel surveillance.

INTERVENTIONS

CE was performed in all patients. Further evaluation via DBE, CTE, or MRE was performed. Definitive treatment was carried out by enteroscopic polypectomy (1 patient), surgical resection (2 patients), and transjugular intrahepatic portosystemic shunt procedure and embolization (1 patient).

MAIN OUTCOME MEASUREMENTS

Detection of significant small-bowel pathology by using DBE, CT, or MRE after a negative capsule study.

RESULTS

Significant small-bowel pathology was missed at CE but was detected by alternative modalities in 5 patients. In 4 patients, the lesions were in the proximal small bowel (adenocarcinoma, malignant melanoma, varices, and stromal tumor). The fifth patient had a large PJS polyp in the proximal ileum.

LIMITATIONS

Retrospective case series with small numbers.

CONCLUSIONS

Gross pathology may be missed at CE, especially in the proximal small bowel, and a negative CE study does not exclude significant disease. Alternative imaging modalities, such as DBE, CTE, or MRE, should be considered when clinical suspicion persists.

Hamartomatous polyposis syndromes

Since the histologic description of the hamartomatous polyp in 1957 by Horrilleno and colleagues, descriptions have appeared of several different syndromes with the propensity to develop these polyps in the upper and lower gastrointestinal tracts. These syndromes include juvenile polyposis, Peutz-Jeghers syndrome, hereditary mixed polyposis syndrome, and the phosphatase and tensin homolog gene (PTEN) hamartoma tumor syndromes (Cowden and Bannayan-Riley-Ruvalcaba syndromes), which are autosomal-dominantly inherited, and Cronkhite-Canada syndrome, which is acquired. This article reviews the clinical aspects, the molecular pathogenesis, the affected organ systems, the risks of cancer, and the management of these hamartomatous polyposis syndromes. Although the incidence of these syndromes is low, it is important for clinicians to recognize these disorders to prevent morbidity and mortality in these patients, and to perform presymptomatic testing in patients at risk.

[Screening and surveillance for hereditary polyposis and non-polyposis syndromes with capsule endoscopy]

The hereditary polyposis syndromes and non-polyposis colorectal carcinoma have been considered as scarcely occurring but inheritable dominant autosomal syndromes. The increasing risk of small bowel carcinoma and prevention of obstruction and intussusception have been making frequent and acute surgical interventions unavoidably led to the necessity of screening and surveillance the patients. Earlier the diagnosis of these symptoms was difficult to establish because traditional radiological methods have a low yield for small polyps. Furthermore, small bowel is only partially accessible with traditional endoscopic techniques such as upper endoscopy, colonoscopy and push-enteroscopy. The "wireless" capsule endoscopy has opened the way then for the non-invasive and painless test of the entire small intestine. - Test results have been cumulated to justify the efficiency and safety of capsule endoscopy concerning the syndromes above. This method can be applied safely even consequently to repeatedly performed surgical interventions by low risk of capsule retention. As the results compared of the diagnosed familial adenomatous polyposis and of Peutz-Jeghers syndrome reflect on capsule endoscopy, its diagnostic sensitiveness is stated as significantly higher than the Barium-contrast X-Ray and MR-enterography. Nevertheless, determination of size and location of polyps has become more problematic when evaluating the test results.

Effectiveness and safety of capsule endoscopy in the diagnosis of small bowel diseases

GOALS

To assess the effectiveness, safety, and clinical use of capsule endoscopy (CE) in the diagnosis of small bowel diseases.

STUDY

Systematic review carried out in the main electronic databases, including MEDLINE, EMBASE, and COCHRANE. Papers were selected independently by the 2 researchers and the quality was determined using a purpose-designed scale.

RESULTS

A total of 9 systematic reviews and 28 original papers were included [11 assessed obscure gastrointestinal bleeding, 9 Crohn's disease (CD), and 4 hereditary polyposis syndromes]. The diagnostic yield of CE for the diagnosis of obscure gastrointestinal bleeding ranged from 39% to 77%. The diagnostic yield of push enteroscopy was lower than 40% in all but 1 study. CE detected suggestive findings in 19% to 71% of patients with suspected CD, whereas radiologic techniques did so in only 0% to 37% of the cases. In patients with suspected recurrence, detection with these techniques was 58% to 81% and 19% to 67%, respectively. Endoscopic capsule detected a greater number of polyps in patients with polyposis syndromes but other techniques allowed for better localization.

CONCLUSIONS

Although CE occupies a preferential place in the diagnosis of gastrointestinal bleeding and CD; there is insufficient evidence to establish whether it could be used as a first line diagnostic test. The evidence is insufficient to ascertain this technique's usefulness in small bowel disorders other than obscure bleeding or CD.

Capsule endoscopy and imaging tests in the elective investigation of small bowel disease

Capsule endoscopy enables high-resolution depiction of small bowel mucosa and has been shown, by several studies, to have a high diagnostic yield in a variety of small bowel diseases. In this review, we critically assess the contributions of capsule endoscopy and imaging tests in common small bowel disorders. Radiological tests that only assess the small bowel mucosa will be less useful in the era of capsule endoscopy.

[Small bowel stromal tumors diagnosed by capsule endoscopy]

Small intestinal stromal tumors account for approximately 35% of all gastrointestinal stromal tumors. Gastrointestinal bleeding is considered as one of the main clinical symptoms for SISTs. Capsule endoscopy has brought revolution in small bowel diagnostics, as it is considered the best method of visualisation of the entire small intestine. Besides, it is well tolerated by patients and is accompanied by a low number of complications. It is also indicated as the first diagnostic method in gastrointestinal bleeding of obscure origin, following negative upper endoscopy and colonoscopy.

CASE REPORT

2 patients (a male and a female, aged 58 and 69, respectively) presented with obscure gastrointestinal bleeding have been examined by capsule endoscopy after negative upper endoscopy and colonoscopy. Videorecords have been assessed in both cases by two independent experts. The capsule reached the Bauchin-valve in both cases during the 8 hours of the testing time and the entire small bowel was clearly visible. - Based on the capsule endoscopic images, for one of the two cases a tumor has been reported as the background of the small intestinal bleeding. In the other case we could mark the location of the bleeding, while we were unable to ascertain the type of the actively bleeding lesion during the test. In order to determine the accurate bleeding source double-balloon enteroscopy was performed in the second case. After surgery the histological and immunohistochemical tests have justified the presence of spindle cell GISTs. Taking into consideration the Fletcher-classification, for the tumor size and the mitotic index, both cases can be classified as a GIST of low malignant potential.

CONCLUSIONS

An early diagnosis and application of a definitive therapy become possible by using capsule endoscopy, therefore the chance of survival of the patients might be increased.

Wireless capsule endoscopy

Wireless capsule endoscopy is a new technique that allows complete exploration of the small bowel without external wires. Its role has been analyzed in many small bowel diseases such as obscure gastrointestinal bleeding, Crohn’s disease and gastrointestinal polyposis syndromes with promising results. Studies on other pathologies (i.e. small bowel tumour, celiac disease) are under evaluation to define the role of this technique.

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

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

Automated topographic segmentation and transit time estimation in endoscopic capsule exams

Endoscopic capsule is a recent medical technology with important clinical benefits but suffering from a practical handicap: long exam annotation times. This paper proposes and compares two approaches (Bayesian and support vector machines) that can be used to segment the gastrointestinal tract into its four major topographic areas, allowing the automatic estimation of the clinically relevant gastric and intestinal sections and corresponding transit times. According to medical specialists, this can reduce exam annotation times by up to 12% (15 min). This automatic tool has been integrated into our CapView annotation software that is currently being used by three medical institutions.

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

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

Capsule endoscopy in the evaluation of gastrointestinal disease

PURPOSE OF REVIEW

The small bowel has been a technically difficult area to examine. Indirect modalities such as barium follow-through have the disadvantage of attendant radiation exposure. Capsule endoscopy, a novel wireless method of investigation of the small bowel, has acquired an important role in both adult and paediatric medicine.

RECENT FINDINGS

The clinical utility of capsule endoscopy has rapidly expanded since its approval by the Food & Drug Administration in the USA in 2001. It has developed an established role in adults, in the investigation of obscure gastrointestinal bleeding, small bowel Crohn's disease, complications of coeliac disease and surveillance of polyposis syndromes. Despite a lag in its use in paediatrics, capsule endoscopy offers an accurate and effective means of investigating the small bowel in children. It has opened up new horizons and permitted a noninvasive approach to identifying occult lesions in the small bowel of children when conventional imaging has been unhelpful.

SUMMARY

This review appraises the current literature to define the clinical indications and practical aspects of capsule endoscopy that are of interest to the paediatrician.

Capsule enteroscopy and radiology of the small intestine

In a very few years, the video capsule for small bowel enteroscopy has gained widespread clinical acceptance. It is readily ingested, disposable, and allows for a complete, low-invasive endoscopic examination of the entire mucosa of the small bowel. It is a patient-friendly method and a first-line procedure in the difficult evaluation of obscure gastrointestinal bleeding. It has the highest proven figure of diagnostic sensitivity for detecting lesions of the mucosa, irrespective of aetiology. The limitations of capsule endoscopy include difficulty in localising mucosal lesions anatomically and its restricted use in patients with dysphagia, strictures or motor dysfunction. Strictures, transmural and extra-mural lesions in patients with small bowel Crohn's disease are evaluated by MRI- enterography and CT-enterography.

Resection of over 290 polyps during emergency surgery for four intussusceptions with Peutz-Jeghers syndrome: Report of a case

A 41-year-old male patient with aggravated epigastralgia and nausea was admitted to Central Aizu General Hospital in February 1997. His past history showed a colonic polyp and anemia in the fourth decade. The patient looked healthy, but showed abdominal distension and tenderness, and pigmented lips. A plain abdominal X-ray revealed a dilation of the small intestine with niveau. Computed tomography disclosed multiple target signs. An emergency laparotomy clarified four intussusceptions of the small intestine with numerous polyps. Three were successfully reduced, while one jejunal intussusception was resected. Due to a fear of recurrence, a total of over 290 polyps were removed. His illness was diagnosed to be Peutz-Jeghers syndrome with a histology of hamartomatous polyps. He thereafter did well for 6 years, when he underwent an ileal resection for another intussusception caused by a newly grown lipoma. He was able to retain his job, but anemia and hypoproteinemia due to the proliferation of polyps necessitated treatments at the outpatient clinic. In May 2005, he underwent a third emergency laparotomy for an intussusception, followed by a resection of the ileum and 54 polyps. Since then he has been able to lead a normal life.

Laparoscopic-assisted double-balloon enteroscopy for small-bowel polyp surveillance and treatment in patients with Peutz-Jeghers syndrome

BACKGROUND

Surveillance and treatment of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS) can be challenging and may require intraoperative enteroscopy. While initial reports that used double-balloon enteroscopy (DBE) for the resection of small-bowel polyps in patients with PJS appear promising, complete enteroscopy when using this technique may require multiple procedures or may not be possible at all.

OBJECTIVE

To develop a single-procedure approach to the surveillance and the treatment of small-bowel polyps in patients with PJS.

DESIGN

Retrospective review.

SETTING

Single, North American tertiary-care center.

PATIENTS

Individuals with PJS and small-bowel polyps identified by other modalities.

INTERVENTIONS

DBE was combined with laparoscopy as a single-procedure surveillance and therapeutic strategy for small-bowel PJS polyps.

MAIN OUTCOME MEASUREMENTS

Completion of enteroscopy, number of polyps resected, procedure duration, complications.

RESULTS

Three patients with a history of PJS and known small-bowel polyps underwent laparoscopic-assisted DBE (LADBE). Complete enteroscopy was performed, and all polyps larger than 0.5 cm were resected endoscopically. No cases of cancer or dysplasia were noted; procedure times lasted from 1 to 4 hours. Postoperative complications included ileus in 2 patients.

LIMITATIONS

Small sample size, single-center experience.

CONCLUSIONS

LADBE holds promise as a new technique that can be used as both a surveillance and a therapeutic tool for small-bowel polyps in patients with PJS.