A pooled analysis to evaluate results of capsule endoscopy trials

Discordance Rate and Risk Factor of Other Diagnostic Modalities for Small Bowel Tumors Detected by Device-Assisted Enteroscopy: A Korean Association for the Study of Intestinal Disease (KASID) Multicenter Study

Background/Aims

Despite advances in imaging and endoscopic technology, diagnostic modalities for small bowel tumors are simultaneously performed. We investigated the discrepancy rate between each modality and predictive factors of discrepancy in patients with definite small bowel tumors.

Methods

Data of patients with definite small bowel tumors who underwent both device-assisted enteroscopy (DAE) and computed tomography (CT) were retrieved from web-based enteroscopy registry database in Korea. Predictive risk factors associated with discrepancy were analyzed using logistic regression analysis.

Results

Among 998 patients, 210 (21.0%) were diagnosed with small bowel tumor using DAE, in 193 patients with definite small bowel tumor, DAE and CT were performed. Of these patients, 12 (6.2%) showed discrepancy between examinations. Among 49 patients who underwent DAE and video capsule endoscopy (VCE) examination, 13 (26.5%) showed discrepancy between examinations. No significant independent risk factors were associated with concordance between DAE and CT in multivariate logistic regression analysis among the patients. In a multivariate logistic regression analysis, red blood cell transfusion was negatively associated with concordance between DAE and VCE in patients with small bowel tumor (odds ratio, 0.163; 95% confidence interval, 0.026 to 1.004; p=0.050).

Conclusions

For small bowel tumors, the discrepancy rate between DAE and CT was 6.2%, and 26.5% between DAE and VCE. Despite developments in cross-sectional imaging (VCE and DAE modalities), discrepancies still exist. For small bowel bleeding that require significant transfusion while showing insignificant VCE findings, DAE should be considered as the next diagnostic approach, considering the possibility of missed small bowel tumor.

Robotic wireless capsule endoscopy: recent advances and upcoming technologies

Wireless capsule endoscopy (WCE) offers a non-invasive evaluation of the digestive system, eliminating the need for sedation and the risks associated with conventional endoscopic procedures. Its significance lies in diagnosing gastrointestinal tissue irregularities, especially in the small intestine. However, existing commercial WCE devices face limitations, such as the absence of autonomous lesion detection and treatment capabilities. Recent advancements in micro-electromechanical fabrication and computational methods have led to extensive research in sophisticated technology integration into commercial capsule endoscopes, intending to supersede wired endoscopes. This Review discusses the future requirements for intelligent capsule robots, providing a comparative evaluation of various methods' merits and disadvantages, and highlighting recent developments in six technologies relevant to WCE. These include near-field wireless power transmission, magnetic field active drive, ultra-wideband/intrabody communication, hybrid localization, AI-based autonomous lesion detection, and magnetic-controlled diagnosis and treatment. Moreover, we explore the feasibility for future "capsule surgeons".

Deep learning in negative small-bowel capsule endoscopy improves small-bowel lesion detection and diagnostic yield

OBJECTIVES

Although several studies have shown the usefulness of artificial intelligence to identify abnormalities in small-bowel capsule endoscopy (SBCE) images, few studies have proven its actual clinical usefulness. Thus, the aim of this study was to examine whether meaningful findings could be obtained when negative SBCE videos were reanalyzed with a deep convolutional neural network (CNN) model.

METHODS

Clinical data of patients who received SBCE for suspected small-bowel bleeding at two academic hospitals between February 2018 and July 2020 were retrospectively collected. All SBCE videos read as negative were reanalyzed with the CNN algorithm developed in our previous study. Meaningful findings such as angioectasias and ulcers were finally decided after reviewing CNN-selected images by two gastroenterologists.

RESULTS

Among 202 SBCE videos, 103 (51.0%) were read as negative by humans. Meaningful findings were detected in 63 (61.2%) of these 103 videos after reanalyzing them with the CNN model. There were 79 red spots or angioectasias in 40 videos and 66 erosions or ulcers in 35 videos. After reanalysis, the diagnosis was changed for 10 (10.3%) patients who had initially negative SBCE results. During a mean follow-up of 16.5 months, rebleeding occurred in 19 (18.4%) patients. The rebleeding rate was 23.6% (13/55) for patients with meaningful findings and 16.1% (5/31) for patients without meaningful findings (P = 0.411).

CONCLUSION

Our CNN algorithm detected meaningful findings in negative SBCE videos that were missed by humans. The use of deep CNN for SBCE image reading is expected to compensate for human error.

CT and MRI of Gastrointestinal Stromal Tumors: New Trends and Perspectives

Gastrointestinal stromal tumors (GISTs) are defined as mesenchymal tumors of the gastrointestinal tract that express positivity for CD117, which is a c-KIT proto-oncogene antigen. Expression of the c-KIT protein, a tyrosine kinase growth factor receptor, allows the distinction between GISTs and other mesenchymal tumors such as leiomyoma, leiomyosarcoma, schwannoma and neurofibroma. GISTs can develop anywhere in the gastrointestinal tract, as well as in the mesentery and omentum. Over the years, the management of GISTs has improved due to a better knowledge of their behaviors and risk or recurrence, the identification of specific mutations and the use of targeted therapies. This has resulted in a better prognosis for patients with GISTs. In parallel, imaging of GISTs has been revolutionized by tremendous progress in the field of detection, characterization, survival prediction and monitoring during therapy. Recently, a particular attention has been given to radiomics for the characterization of GISTs using analysis of quantitative imaging features. In addition, radiomics has currently many applications that are developed in conjunction with artificial intelligence with the aim of better characterizing GISTs and providing a more precise assessment of tumor burden. This article sums up recent advances in computed tomography and magnetic resonance imaging of GISTs in the field of image/data acquisition, tumor detection, tumor characterization, treatment response evaluation, and preoperative planning.

The Role of Capsule Endoscopy in the Diagnosis and Management of Small Bowel Tumors: A Narrative Review

Small bowel tumors (SBT) are relatively rare, but have had a steadily increasing incidence in the last few decades. Small bowel capsule endoscopy (SBCE) and device-assisted enteroscopy are the main endoscopic techniques for the study of the small bowel, the latter additionally providing sampling and therapeutic options, and hence acting complementary to SBCE in the diagnostic work-up. Although a single diagnostic modality is often insufficient in the setting of SBTs, SBCE is a fundamental tool to drive further management towards a definitive diagnosis. The aim of this paper is to provide a concise narrative review of the role of SBCE in the diagnosis and management of SBTs.

MUTYH-associated polyposis: Is it time to change upper gastrointestinal surveillance? A single-center case series and a literature overview

BACKGROUND

The presence of Spigelman stage (SS) IV duodenal polyposis is considered the most significant risk factor for duodenal cancer in patients with MUTYH-associated polyposis (MAP). However, advanced SS disease is rarely reported in MAP patients, and no clear recommendations on small bowel (SB) surveillance have been proposed in this patient setting.

AIM

To research more because that case reports of duodenal cancers in MAP suggest that they may develop in the absence of advanced benign SS disease and often involve the distal portion of the duodenum.

METHODS

We describe a series of MAP patients followed up at the Regina Elena National Cancer Institute of Rome (Italy). A literature overview on previously reported SB cancers in MAP is also provided.

RESULTS

We identified two (6%) SB adenocarcinomas with no previous history of duodenal polyposis. Our observations, supported by literature evidence, suggest that the formula for staging duodenal polyposis and predicting risk factors for distal duodenum and jejunal cancer may need to be adjusted to take this into account rather than focusing solely on the presence or absence of SS IV disease.

CONCLUSION

Our study emphasizes the need for further studies to define appropriate upper gastrointestinal surveillance programs in MAP patients.

Video capsule endoscopy versus computed tomography enterography in assessing suspected small bowel bleeding: a systematic review and diagnostic test accuracy meta-analysis

Both computed tomography enterography (CTE) and video capsule endoscopy (VCE) are used in identifying small intestinal pathology in patients with suspected small bowel bleeding (SSBB) following normal upper gastrointestinal endoscopy and colonoscopy. Evidence of the comparative accuracy of these two modalities is crucial for clinical and healthcare decision-making. Comprehensive electronic searches were performed for studies on CTE and/or VCE with reference standard(s). Study selection, data extraction and quality assessment were completed by two authors independently. The QUADAS-2 and QUADAS-C tools were used to assess risk of bias, and applicability. Meta-analysis was performed using a bivariate model to obtain summary estimates of sensitivity, specificity, positive and negative likelihood ratios. Twenty-five studies involving 1986 patients with SSBB were included. Four of these were head-to-head comparison of CTE and VCE. Overall, VCE provided significantly higher sensitivity of 0.74 (95% CI: 0.61-0.83) versus 0.47 (95% CI: 0.32-0.62) for CTE, while CTE showed significantly higher specificity of 0.94 (95% CI: 0.64-0.99) versus 0.53 (95% CI: .36-0.69) for VCE. The positive likelihood ratio of CTE was 7.36 (95% CI: 0.97-56.01) versus 1.58 (95% CI: 1.15-2.15) for VCE and the negative likelihood ratio was 0.49 (95% CI: 0.33-0.72) for VCE versus 0.56 (0.40-0.79) for CTE. A secondary analysis of only head-to-head comparative studies gave results that were similar to the main analysis. Certainty of evidence was moderate. Neither VCE nor CTE is a perfect test for identifying etiology of SSBB in small intestine. VCE was more sensitive while CTE was more specific. Clinicians should choose the appropriate modality depending on whether better sensitivity or specificity is required in each clinical scenario.

Updates in the diagnosis and management of small-bowel tumors

Small-bowel tumors represent a rare entity comprising 0.6% of all new cancer cases in the US, and only 3% of all gastrointestinal neoplasms. They are a heterogenous group of neoplasms comprising of about forty different histological subtypes with the most common being adenocarcinoma, neuroendocrine tumors, stromal tumors and lymphomas. Their incidence has been reportedly increasing over recent years, partly owing to the advances and developments in the diagnostic modalities. Small-bowel capsule endoscopy, device assisted enteroscopy and dedicated small-bowel cross-sectional imaging are complimentary tools, supplementing each other in the diagnostic process. Therapeutic management of small-bowel tumors largely depends on the histological type and staging at diagnosis. The aim of the present review article is to discuss relevant advances in the diagnosis and management of small-bowel tumors.

Artificial intelligence in gastroenterology: A narrative review

Artificial intelligence (AI) is a complex concept, broadly defined in medicine as the development of computer systems to perform tasks that require human intelligence. It has the capacity to revolutionize medicine by increasing efficiency, expediting data and image analysis and identifying patterns, trends and associations in large datasets. Within gastroenterology, recent research efforts have focused on using AI in esophagogastroduodenoscopy, wireless capsule endoscopy (WCE) and colonoscopy to assist in diagnosis, disease monitoring, lesion detection and therapeutic intervention. The main objective of this narrative review is to provide a comprehensive overview of the research being performed within gastroenterology on AI in esophagogastroduodenoscopy, WCE and colonoscopy.

"MURAL" model to predict bleeding from mural-based lesions in potential small bowel bleeding may improve diagnostic capability and decrease cost

In potential small bowel bleeding, video capsule endoscopy (VCE) is excellent to detect mucosal lesions, while mural-based lesions are better detected by computed tomography enterography (CTE). A predictive tool to identify mural-based lesions should guide selecting investigations. In this retrospective study, we developed and validated the "MURAL" model based on logistic regression to predicts bleeding from mural-based lesions. Cost-effectiveness analysis comparing diagnostic strategy among VCE, CTE, and MURAL model was performed. Of 296 patients, 196 and 100 patients were randomly included in the derivative and validation cohorts, respectively. The MURAL model comprises 5 parameters: age, presence of atherosclerosis, chronic kidney disease, antiplatelet use, and serum albumin level. The area under the receiver operating characteristic curve was 0.778 and 0.821 for the derivative and validation cohorts, respectively. At a cutoff value of 24.2%, the model identified mural-based lesions with 70% sensitivity and 83% specificity in the validation cohort. Cost-effectiveness analysis revealed that application of the MURAL model demonstrated a comparable missed lesion rate but had a lower missed tumor rate, and lower cost compared to VCE strategy. The model for predicting mural-based lesions provide some guidance in investigative decision-making, which may improve diagnostic efficiency and reduce costs.

Technological advances in inflammatory bowel disease endoscopy and histology

Accurate disease characterization is the pillar of modern treatment of inflammatory bowel disease (IBD) and endoscopy is the mainstay of disease assessment and colorectal cancer surveillance. Recent technological progress has enhanced and expanded the use of endoscopy in IBD. In particular, numerous artificial intelligence (AI)-powered systems have shown to support human endoscopists' evaluations, improving accuracy and consistency while saving time. Moreover, advanced optical technologies such as endocytoscopy (EC), allowing high magnification in vivo, can bridge endoscopy with histology. Furthermore, molecular imaging, through probe based confocal laser endomicroscopy allows the real-time detection of specific biomarkers on gastrointestinal surface, and could be used to predict therapeutic response, paving the way to precision medicine. In parallel, as the applications of AI spread, computers are positioned to resolve some of the limitations of human histopathology evaluation, such as interobserver variability and inconsistencies in assessment. The aim of this review is to summarize the most promising advances in endoscopic and histologic assessment of IBD.

Recent developments in wireless capsule endoscopy imaging: Compression and summarization techniques

Wireless capsule endoscopy (WCE) can be viewed as an innovative technology introduced in the medical domain to directly visualize the digestive system using a battery-powered electronic capsule. It is considered a desirable substitute for conventional digestive tract diagnostic methods for a comfortable and painless inspection. Despite many benefits, WCE results in poor video quality due to low frame resolution and diagnostic accuracy. Many research groups have presented diversified, low-complexity compression techniques to economize battery power consumed in the radio-frequency transmission of the captured video, which allows for capturing the images at high resolution. Many vision-based computational methods have been developed to improve the diagnostic yield. These methods include approaches for automatically detecting abnormalities and reducing the amount of time needed for video analysis. Though various research works have been put forth in the WCE imaging field, there is still a wide gap between the existing techniques and the current needs. Hence, this article systematically reviews recent WCE video compression and summarization techniques. The review's objectives are as follows: First, to provide the details of the requirement, challenges and design percepts for the low complexity WCE video compressor. Second, to discuss the most recent compression methods, emphasizing simple distributed video coding methods. Next, to review the most recent summarization techniques and the significance of using deep neural networks. Further, this review aims to provide a quantitative analysis of the state-of-the-art methods along with their advantages and drawbacks. At last, to discuss existing problems and possible future directions for building a robust WCE imaging framework.

A Gastroenterologist's Approach to the Diagnosis and Management of Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. These tumors have been shown to harbor oncogenic mutations of the c-kit tyrosine kinase receptor or platelet-derived growth factor receptor alpha (PDGFRA). Immunohistochemical analysis of GISTs allows for the differentiation of these tumors from other mesenchymal tumors of the GI tract such as leiomyomas and leiomyosarcomas. All GISTs have the potential to behave in a malignant fashion. Tumor location, size, and mitotic index are factors used to predict the risk of malignant behavior. Endoscopy and endoscopic ultrasound play a critical role in the diagnosis of GISTs and can yield important information to further risk-stratify tumors and determine management. This article provides a gastroenterologist's perspective on the diagnosis and management of GISTs.

Gastrointestinal disorders in children with autism: Could artificial intelligence help?

Autism is one of the pervasive neurodevelopmental disorders usually associated with many medical comorbidities. Gastrointestinal (GI) disorders are pervasive in children, with a 46%-84% prevalence rate. Children with Autism have an increased frequency of diarrhea, nausea and/or vomiting, gastroesophageal reflux and/or disease, abdominal pain, chronic flatulence due to various factors as food allergies, gastrointestinal dysmotility, irritable bowel syndrome (IBS), and inflammatory bowel diseases (IBD). These GI disorders have a significant negative impact on both the child and his/her family. Artificial intelligence (AI) could help diagnose and manage Autism by improving children's communication, social, and emotional skills for a long time. AI is an effective method to enhance early detection of GI disorders, including GI bleeding, gastroesophageal reflux disease, Coeliac disease, food allergies, IBS, IBD, and rectal polyps. AI can also help personalize the diet for children with Autism by microbiome modification. It can help to provide modified gluten without initiating an immune response. However, AI has many obstacles in treating digestive diseases, especially in children with Autism. We need to do more studies and adopt specific algorithms for children with Autism. In this article, we will highlight the role of AI in helping children with gastrointestinal disorders, with particular emphasis on children with Autism.

Small bowel adenocarcinoma: An overview

Small bowel adenocarcinoma (SBA) is a rare malignancy of the gastrointestinal tract. However, these tumors are among those with worst prognosis. Vague clinical signs and symptoms and radiological diagnostic challenges often delay treatment, which negatively impacts the prognosis of the patients. However, recent advances in imaging technology, like multidetector computed tomography, magnetic resonance imaging, and capsule endoscopy, have made earlier and accurate diagnosis possible. Surgery is the treatment of choice followed by adjuvant therapy. However, there are no strict treatment guidelines available for the management of SBA. Most of the available evidence from colorectal and gastric carcinoma has been extrapolated to adequately manage SBA. Prognosis for SBA is better than gastric carcinoma but worse than colorectal carcinoma. Currently, there is not enough information on the molecular characteristics and tumor pathogenesis. Because the incidence of SBA is very low, there is a need for further studies to evaluate the possible application of newer investigative agents and strategies to obtain a better outcome within the framework of international collaborations.

Evolution and New Horizons of Endoscopy in Inflammatory Bowel Diseases

Endoscopy is the mainstay of inflammatory bowel disease (IBD) evaluation and the pillar of colorectal cancer surveillance. Endoscopic equipment, both hardware and software, are advancing at an incredible pace. Virtual chromoendoscopy is now widely available, allowing the detection of subtle inflammatory changes, thus reducing the gap between endoscopic and histologic assessment. The progress in the field of artificial intelligence (AI) has been remarkable, and numerous applications are now in an advanced stage of development. Computer-aided diagnosis (CAD) systems are likely to reshape most of the evaluations that are now prerogative of human endoscopists. Furthermore, sophisticated tools such as endocytoscopy and probe-based confocal laser endomicroscopy (pCLE) are enhancing our assessment of inflammation and dysplasia. Finally, pCLE combined with molecular labeling could pave the way to a new paradigm of personalized medicine. This review aims to summarize the main changes that occurred in the field of IBD endoscopy and to explore the most promising novelties.

The Evolution of Device-Assisted Enteroscopy: From Sonde Enteroscopy to Motorized Spiral Enteroscopy

The introduction of capsule endoscopy in 2001 opened the last "black box" of the gastrointestinal tract enabling complete visualization of the small bowel. Since then, numerous new developments in the field of deep enteroscopy have emerged expanding the diagnostic and therapeutic armamentarium against small bowel diseases. The ability to achieve total enteroscopy and visualize the entire small bowel remains the holy grail in enteroscopy. Our journey in the small bowel started historically with sonde type enteroscopy and ropeway enteroscopy. Currently, double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy are available in clinical practice. Recently, a novel motorized enteroscope has been described with the potential to shorten procedure time and allow for total enteroscopy in one session. In this review, we will present an overview of the currently available techniques, indications, diagnostic yield, and complications of device-assisted enteroscopy.

Risk of Rebleeding in Patients with Small Bowel Vascular Lesions

Objective With recent advances in endoscopic modalities, small bowel vascular lesions (SBVLs) are often now detected in patients with gastrointestinal bleeding. Given the high invasiveness of endoscopic treatment, it is important to select patients at high risk for bleeding. To assess the risk of rebleeding in patients with SBVLs as a systemic disease rather than a gastrointestinal disease in relation to their general health. Methods We retrospectively analyzed the clinical data of 55 patients with SBVLs among patients with obscure gastrointestinal bleeding. The possible association between the clinical findings and the updated Charlson comorbidity index with rebleeding was evaluated. Results Gastrointestinal rebleeding occurred in 20 patients (36.4%) during the follow-up period. The presence of multiple comorbidities as indicated by an updated Charlson comorbidity index of ≥4 was a risk factor for rebleeding (hazard ratio, 3.64; p=0.004). Other risk factors were arteriosclerosis of the superior mesenteric artery and multiple SBVLs. Endoscopic hemostasis and the discontinuation of antithrombotic medications were not significantly associated with rebleeding. Patients with a high updated Charlson comorbidity index had a high risk of death of causes other than gastrointestinal rebleeding. Conclusion Gastrointestinal rebleeding is not a rare condition among patients with SBVLs. Patients with poor general health may therefore have a higher risk of rebleeding.

Capsule Endoscopy: Pitfalls and Approaches to Overcome

Capsule endoscopy of the gastrointestinal tract is an innovative technology that serves to replace conventional endoscopy. Wireless capsule endoscopy, which is mainly used for small bowel examination, has recently been used to examine the entire gastrointestinal tract. This method is promising for its usefulness and development potential and enhances convenience by reducing the side effects and discomfort that may occur during conventional endoscopy. However, capsule endoscopy has fundamental limitations, including passive movement via bowel peristalsis and space restriction. This article reviews the current scientific aspects of capsule endoscopy and discusses the pitfalls and approaches to overcome its limitations. This review includes the latest research results on the role and potential of capsule endoscopy as a non-invasive diagnostic and therapeutic device.

Artificial Intelligence in Capsule Endoscopy: A Practical Guide to Its Past and Future Challenges

Artificial intelligence (AI) has revolutionized the medical diagnostic process of various diseases. Since the manual reading of capsule endoscopy videos is a time-intensive, error-prone process, computerized algorithms have been introduced to automate this process. Over the past decade, the evolution of convolutional neural network (CNN) enabled AI to detect multiple lesions simultaneously with increasing accuracy and sensitivity. Difficulty in validating CNN performance and unique characteristics of capsule endoscopy images make computer-aided reading systems in capsule endoscopy still on a preclinical level. Although AI technology can be used as an auxiliary second observer in capsule endoscopy, it is expected that in the near future, it will effectively reduce the reading time and ultimately become an independent, integrated reading system.

Small bowel adenocarcinoma: Case reports and review of the literature

Small bowel adenocarcinomas (SBAs) are rare tumors of the gastrointestinal tract. Patients often present with advanced disease due to nonspecific symptoms and delayed diagnoses. In combination with non-uniform treatment paradigms, patients who present with SBA often have poor prognoses. In this case series, we present four cases of SBA and review the most recent literature with regard to diagnosis and management. One patient presented with iron-deficient anemia (IDA), and three patients presented with clinical obstruction. The patient with IDA was subjected to protracted investigations, whereas the three patients with obstruction were diagnosed quickly after presentation. All four patients underwent surgical resection, and one patient was eligible for post-operative adjuvant chemotherapy. SBA should be highly suspected in patients who present with occult gastrointestinal bleeds, and appropriate investigations must be initiated. Following diagnosis, surgical resection is the mainstay of treatment for this disease. Our review supports the use of both neoadjuvant and adjuvant chemotherapy in localized disease.

Evaluation of a new composite score combining SPICE and Protrusion Angle scores to distinguish submucosal lesions from innocent bulges

Introduction/Aims In capsule endoscopy (CE), small bowel subepithelial lesions (SBSL) are difficult to distinguishing from innocent mucosal protrusions. The SPICE score (smooth, protruding lesions index on CE) and a score that assesses the SBSL protrusion angle were developed. We intend to determine if a composite score is superior to the proposed models. Methods All CE between 01/2010 and 12/2020 were included if a smooth, round protruding lesion was identified. Both scores and a composite score (SPICE>2 and Angle<90º) were calculated after video review. Mucosal protrusions were defined as SBSL if they had a histological/imaging diagnosis and innocent protrusions if otherwise. All patients without at least one appointment and an additional diagnostic exam after CE were excluded. Results A total of 34 CE included, 64.7% men, age 65.4±14.7 years. The most common indication for CE was anemia (52.9%). SBSL were identified in 17 cases, with lipomas (14.7%) being the most frequent diagnosis. Both the SPICE (AUROC 0.90, p<0.001) and protrusion angle scores (AUROC 0.74, p=0.019) accurately distinguished SBSL from innocent protrusions. Applying a 90º cut-off, the protrusion angle has a sensitivity of 52.9% and specificity of 88.2%. Applying a cut-off of >2 points, the SPICE score has a sensitivity of 64.7% and specificity of 94.2%. The composite score had a sensitivity, specificity, positive and negative predictive value of 47.0%, 100%, 100% and 65.4%. Conclusion We propose that in cases where both a SPICE>2 and angle of <90º are obtained, additional follow-up investigation should always be undertaken, as the likelihood of SBSL is high.

Negative Video Capsule Endoscopy Had a High Negative Predictive Value for Small Bowel Lesions, but Diagnostic Capability May Be Lower in Young Patients with Overt Bleeding

BACKGROUND

Patients with potential small bowel bleeding (PSBB) who have negative results of video capsule endoscopy (VCE), clinical course, rate of rebleeding, and missed lesions with their predictors are essential for further management decision.

METHODS

This retrospective study included patients presenting with PSBB who had negative VCE findings between January 2008 and December 2016. All patients had to have at least two years of follow-up data to be included. Patients with <2 years of follow-up in their medical record were interviewed by telephone to determine if any unrecorded rebleeding episodes occurred.

RESULTS

One hundred forty-two patients were included. The mean age was 60.9 years, and 52.8% were male. Eighty-one patients presented with overt bleeding. The median duration of follow-up was 5.08 years. During the follow-up period, 30 patients experienced rebleeding. The cumulative rate of rebleeding at 1, 2, and 5 years was 10.0%, 14.3%, and 22.4%, respectively. Multivariate analysis showed nonsteroidal anti-inflammatory drugs (NSAIDs) and presentation of overt bleeding to be independent predictors of rebleeding. There were only nine small bowel lesions (6.3%) missed by VCE. These nine patients, compared with others, were significantly younger and tended to present with overt bleeding.

CONCLUSION

Rebleeding was not uncommon in PSBB after negative VCE; however, the rate of missing small bowel lesions was low. Nonetheless, further investigations may be considered in young patients who present with overt bleeding.

The Role of Endoscopy in Small Bowel Neuroendocrine Tumors

Small bowel neuroendocrine tumors (NETs) represent approximately one-third of NETs of the gastrointestinal tract, and their incidence is increasing. When determining if endoscopic resection is appropriate, endoscopic ultrasound is used to assess the lesion size and depth of invasion for duodenal NETs. A number of techniques, including endoscopic mucosal resection (EMR), band-assisted EMR (band-EMR), endoscopic submucosal dissection (ESD), and over-the-scope clip-assisted endoscopic full-thickness resection (EFTR), have been studied; however, the best technique for endoscopic resection remains unclear. The vast majority of currently available data are retrospective, and prospective studies with longer follow-up times are required. For jejunal and ileal NETs, endoscopic techniques such as video capsule endoscopy (VCE) and balloon enteroscopy (BE) assist in diagnosis. This includes localization of the primary NET in metastatic disease where initial workup has been negative, and the identification of multifocal disease, which may change management and prognostication.

Role of Video Capsule Endoscopy as a Prelude to Deep Enteroscopy

Video capsule endoscopy and device-assisted enteroscopy are complementary technologies. Capsule endoscopy is a highly acceptable technology with high diagnostic yield that can guide a subsequent enteroscopy approach. This article aims to focus on the role of video capsule endoscopy as a prelude to deep enteroscopy with a focus on the strengths and limitations of either approach.

Role of Video Capsule in Small Bowel Bleeding

Video capsule endoscopy has an essential role in the diagnosis and management of small bowel bleeding and is the first-line study recommended for this purpose. This article reviews the risk factors for small bowel bleeding, optimal timing for video capsule endoscopy testing, and algorithms recommended for evaluation. Used primarily for the assessment of nonacute gastrointestinal blood loss, video capsule endoscopy has an emerging role for more urgent use in emergency settings and in special populations. Future software incorporation of neural networks to enhance lesion detection will likely result in an augmented role of video capsule endoscopy in small bowel bleeding.

The Role of Provocative Testing and Localization of the Video Capsule Endoscope in the Management of Small Intestinal Bleeding

The cause of small intestinal bleeding (SIB) may be elusive despite exhaustive testing. This article describes the current understanding of SIB regarding evaluation, with emphasis on the use of video capsule endoscopy (VCE) as a diagnostic procedure. This article addresses the utility of provocative testing in challenging cases and the performance of endoscopic procedures on active antithrombotic therapy. Specific recommendations accompany this article, including use of antithrombotic agents to stimulate bleeding when clearly indicated; performance of endoscopic procedures on active antithrombotic therapy; and progressive adoption of VCE and device-assisted enteroscopy in the inpatient setting.

Double-headed small-bowel capsule endoscopy: Real-world experience from a multi-centre British study

INTRODUCTION

Capsule endoscopy (CE) is well established the investigation of small-bowel (SB) pathology. We compared the use of double-headed (DH) capsules, to conventional single-headed (SH), in a real-world patient cohort in the first multicentre British study.

METHODS

Over 9 months, patients referred for routine SBCE at 4 tertiary referral centres in the UK underwent DH CE instead of conventional SH using MiroCam^Ⓡ MC2000 as per local protocols. One head (L/R) was chosen at random and reported by an expert reviewer. The DH recordings, anonymised and randomised, reported by another expert or re-read after a 4-week interval. For each CE, numbers and types of findings and overall conclusion/diagnosis were compared between SH and DH examinations.

RESULTS

211 CEs were performed. 7 failed to reach the SB; 204 analysed. Indications were: SB bleeding (n = 94); ?SB inflammation or reassessment of known inflammatory bowel disease (IBD) (n = 84); ?SB neoplasia including suspicious radiological imaging (n = 15); and, others e.g. ?celiac disease (n = 11). For SB bleeding: 27/94 (28.7%) examinations reported differences between SH and DH readings. In 17 (18.1%) the findings were clinically significant. SH CE missed angiectasias (5 pts), SB inflammation (7 pts), oesophagitis (2 pts) and SB masses (2 pts). In 1 patient, the extent of angiectasias seen was greater on the DH reading. For IBD: findings differed in 30/84 (35.7%) of CEs; 11 (13.1%) were clinically significant. In 5, signs of active inflammation were missed by the SH reading. In 6, assessment of extent/severity differed. For?SB neoplasia findings differed in 2/15 (13.3%) of examinations. Both were clinically significant. For others: 1/11 (9.1%) examinations differed; however, not deemed clinically significant. Overall, use of DH CE impacted the diagnosis in 30/204 (14.7%).

CONCLUSIONS

The use of DH CE provides more information with the potential to change clinical diagnosis and therefore management. Therefore, the routine adoption of DH CE in SB assessment should be considered.

How should we do colon capsule endoscopy reading: a practical guide

In this article, we aim to provide general principles as well as personal views for colonic capsule endoscopy. To allow an in-depth understanding of the recommendations, we also present basic technological characteristics and specifications, with emphasis on the current as well as the previous version of colonic capsule endoscopy and relevant software. To date, there is no scientific proof to support the optimal way of reading a colonic capsule endoscopy video, or any standards or guidelines exist. Hence, any advice is a mixture of recommendations by the capsule manufacturer and experts’ opinion. Furthermore, there is a paucity of data regarding the use of term(s) (pre-reader/reader-validator) in colonic capsule endoscopy. We also include a couple of handy tables in order to get info at a glance.

Artificial intelligence and deep learning for small bowel capsule endoscopy

Capsule endoscopy is ideally suited to artificial intelligence-based interpretation given its reliance on pattern recognition in still images. Time saving viewing modes and lesion detection features currently available rely on machine learning algorithms, a form of artificial intelligence. Current software necessitates close human supervision given poor sensitivity relative to an expert reader. However, with the advent of deep learning, artificial intelligence is becoming increasingly reliable and will be increasingly relied upon. We review the major advances in artificial intelligence for capsule endoscopy in recent publications and briefly review artificial intelligence development for historical understanding. Importantly, recent advancements in artificial intelligence have not yet been incorporated into practice and it is immature to judge the potential of this technology based on current platforms. Remaining regulatory and standardization hurdles are being overcome and artificial intelligence-based clinical applications are likely to proliferate rapidly.

Roles of Capsule Endoscopy and Device-Assisted Enteroscopy in the Diagnosis and Treatment of Small-Bowel Tumors

With the development of capsule endoscopy (CE) and device-assisted enteroscopy (DAE), the incidence of small-bowel tumors has increased and the characteristics of these tumors have changed. In addition, the diagnostic and therapeutic approaches for small-bowel tumors have diversified. CE is a simple, noninvasive method that aid in the visualization the entire small bowel. CE is considered the initial approach for small-bowel tumors. DAE can be used to perform endoscopic procedures such as bleeding control, polypectomy, stent insertion, and tattooing, as well as for diagnosis through visualization or tissue sampling. Therapeutic intervention with DAE is particularly useful in polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome. This review will discuss the roles of CE and DAE in the diagnosis and treatment of small-bowel tumors.

Comparison of Lewis Score and Capsule Endoscopy Crohn's Disease Activity Index in Patients with Crohn's Disease

BACKGROUND/AIMS

Small bowel capsule endoscopy (SBCE) is used to visualize mucosal inflammatory changes in the small intestine of patients with Crohn's disease (CD). The Lewis score (LS) and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) are used to evaluate the visualized images. We determined the score disagreement between LS and CECDAI in patients with CD.

METHODS

We evaluated 184 SBCE procedures in 102 CD patients with small bowel lesions. Patients were classified according to the Montreal classification. LS and CECDAI were calculated, and cases with disagreement between the two scores were identified. We investigated the characteristics of disagreement, and analyzed the relationships with the Crohn's Disease Activity Index (CDAI) and C-reactive protein.

RESULTS

LS (504 ± 1160) correlated strongly with CECDAI (6 ± 5.4) (Spearman's rank correlation coefficient ρ = 0.81, p < 0.0001). LS values of 135 and 790 were equivalent to CECDAI values of 4.9 and 6.9, respectively. The inflammatory changes by LS were significantly observed in several tertiles in the CECDAI discrepancy group (LS < 135, CECDAI ≥ 4.9) compared with the normal agreement group (LS < 135, CECDAI < 4.9) (p < 0.0001). In both groups, CDAI was also significantly different between Montreal L1 and L3 groups (p = 0.0232, p = 0.0196, respectively). LS inflammation score was 0 in six cases in the LS discrepancy group (LS ≥ 135, CECDAI ≤ 4.9, n = 10); the high LS scores were in patients with high stricture scores.

CONCLUSIONS

Discrepancies between the LS and CECDAI scores were observed in some patients. Cases with high CECDAI alone exhibited extensive inflammation and high disease activity (clinical symptoms and biomarker levels). CECDAI seems to better reflect active intestinal inflammation than LS.

Rare presentation of small bowel adenocarcinoma with neuroendocrine differentiation in the jejunum: A case report and summary of diagnostic and management options

Cancer of the small bowel (SB) is rare. The most common SB malignancy is neuroendocrine, followed by adenocarcinoma. SB adenocarcinoma with overlapping neuroendocrine differentiation (NED) is very uncommon. The present case report discusses the case of a young African American female who presented with high-grade SB perforation and underwent urgent surgical repair. Histology of the tumor revealed jejunal adenocarcinoma with NED. To the best of our knowledge, this type of tumor has not yet been reported in the jejunum. Referring patients that present with insidious and nonspecific abdominal discomfort for imaging studies that are more sensitive to the SB could potentially identify tumors earlier, prevent the development of emergent gastrointestinal complications and offer a chance for cure. An overview of diagnostic tools for SB evaluation was provided.

The Spectrum of Small Intestinal Lesions in Patients with Unexplained Iron Deficiency Anemia Detected by Video Capsule Endoscopy

Background and objectives: Video-capsule endoscopy (VCE) has shown a large range (38⁻83%) of diagnostic yield in unexplained iron deficiency anemia (IDA) and obscure-occult bleeding. Therefore, we retrospectively investigated the VCE-detected spectrum and the prevalence of small bowel injuries and associated risk factors in inpatients with both of the above reported conditions. Methods: We selected inpatients with IDA (hemoglobin <12 g/dL in women, <13 g/dL in men) and obscure-occult bleeding. We excluded VCE indications other than IDA. Complete medical histories and laboratory tests were collected. All subjects underwent PillCam SB2/SB3. The VCE feature Lewis score was calculated when appropriate. We used the t-test and Fisher's exact test for continuous and categorical variables, respectively, in univariate analysis. For multivariate analysis, we used binomial logistic regression. Results: We retrieved 109 patients (female:male ratio of 53:56; age 63.4 ± 18.9 years). Eighty patients (73.4%) showed ≥1 small bowel lesions. The Lewis score was calculated in 41 patients: 13 (31.7%) showed a mild (<135) and 28 (68.3%) a moderate-severe (135⁻790 and >790, respectively) score. In univariate analysis, the small bowel transit time (6.2 ± 2.9 versus 5.2 ± 2.1 h; p = 0.049) and non-steroidal anti-inflammatory drug use for at least two weeks (17.5% versus 0%; p = 0.01) were significantly higher in subjects with injuries. These associations were not confirmed at multivariate analysis. The severity of a lesion directly correlated with proton pump inhibitor (PPI) use and duration (not confirmed in multivariate analysis). VCE can reveal the source of obscure-occult bleeding in a high percentage of unexplained IDAs. A wide spectrum of endoscopic pictures may be found. Known as well as supposed risk factors for small bowel lesions may be detected.

[Small Bowel Tumors and Polyposis: How to Approach and Manage?]

Although small bowel the mainly occupies the most part of the gastrointestinal tract, small intestine tumors are rare, insidious in clinical presentation, and frequently represent a diagnostic and management challenge. Small bowel tumors are generally classified as epithelial, mesenchymal, lymphoproliferative, or metastatic. Familial adenomatous polyposis and Peutz-Jeghers syndrome are the most common inherited intestinal polyposis syndromes. Until the advent of capsule endoscopy (CE) and device-assisted enteroscopy (DAE) coupled with the advances in radiology, physicians had limited diagnostic examination for small bowel examination. CE and new radiologic imaging techniques have made it easier to detect small bowel tumors. DAE allows more diagnosis and deeper reach in small intestine. CT enteroclysis/CT enterography (CTE) provides information about adjacent organs as well as pictures of the intestinal lumen side. Compared to CTE, Magnetic resonance enteroclysis/enterography provides the advantage of soft tissue contrast and multiplane imaging without radiation exposure. Treatment and prognosis are tailored to each histological subtype of tumors.

Non-small bowel lesion detection at small bowel capsule endoscopy: A comprehensive literature review

Small bowel capsule endoscopy is a minimally-invasive endoscopic investigation that is often used in clinical practice to investigate overt or occult gastrointestinal (GI) bleeding among other clinical indications. International guidance recommends small bowel capsule endoscopy as a first-line investigation to detect abnormalities in the small bowel, when gastroscopy and colonoscopy fail to identify a cause of GI bleeding. It can diagnose with accuracy abnormalities in the small bowel. However, there has been increasing evidence indicating that small bowel capsule endoscopy may also detect lesions outside the small intestine that are within the reach of conventional endoscopy and have been probably missed during prior endoscopic investigations. Such lesions vary from vascular deformities to malignancy and their detection often alters patient management, leading to further endoscopic and/or surgical interventions. The current study attempts to review all available studies in the literature and summarise their relevant findings.

The evolving management of small bowel adenocarcinoma

BACKGROUND

Small bowel adenocarcinoma (SBA) is rare despite the fact that the small bowel represents the longest part and has the largest surface of all alimentary tract sections. Its incidence is 50-fold lower than that of colorectal carcinoma. It is often diagnosed at an advanced stage due to atypical and late symptoms, its low index of suspicion, difficult endoscopic access and poor detection by radiological imaging, resulting in impaired outcome. Due to its rarity and being molecularly a unique intestinal cancer, data regarding its optimal management are relatively sparse.

MATERIAL AND METHODS

A PubMed search was performed to identify relevant manuscripts that were recently published. Emerging data regarding the pathogenesis, the diagnosis and the treatment of SBA that resulted from recent research are discussed in this comprehensive review.

RESULTS

Genomic analysis has demonstrated that SBA is a molecularly unique intestinal cancer. Double balloon enteroscopy and capsule endoscopy are novel techniques which may result in earlier diagnosis and consequently in improvement of the generally poor prognosis. For clinically localized disease, the quality of surgery has recently been defined, with removal of at least 8-10 lymph nodes correlating with improved prognosis. Moreover, adjuvant chemotherapy seems to improve outcome of stage III disease. The combination of a fluoropyrimidine and oxaliplatin appears to be the most effective systemic chemotherapy for disseminated disease. Genomic profiling can identify potentially targetable genomic alterations in a significant proportion of SBA patients. The role of administration of targeted agents or immune checkpoint inhibitors is still unknown and subject of ongoing clinical trials. In the common case of peritoneal metastases, recent studies have shown that cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy may be an attractive treatment option in selected patients.

CONCLUSIONS

SBA is a rare and unique malignancy, whose diagnostic approach and treatment are evolving, resulting in improved outcome.

Small bowel tumours: update in diagnosis and management

PURPOSE OF REVIEW

The aim of this study was to summarize the role of recently developed diagnostic techniques in the diagnosis and management of patients with small bowel tumours (SBTs).

RECENT FINDINGS

Recent studies show that the overall SBT incidence is increasing. The introduction of small bowel dedicated diagnostic tools [i.e. capsule endoscopy, device-assisted enteroscopy (DAE), computed tomography (CT) and MRI-enterography] might partially explain this trend. In patients with SBT, DAE might represent an ideal tool by coupling careful mucosal inspection with sampling capability. Unfortunately, DAE is an invasive procedure and seldom allows complete small bowel evaluation in a single setting. Therefore, DAE is more often used in clinical practice as confirmatory tool, when other less invasive and readily available tests (i.e. capsule endoscopy or radiological tests) identify relevant findings. Nevertheless, in patients with SBT, capsule endoscopy is burdened by an increased risk of capsule retention and/or missing proximal small bowel lesions, whereas dedicated cross-sectional imaging techniques often identify nonspecific findings of limited clinical significance.

SUMMARY

Despite recent technical improvements, in patients with SBT, the result of a single diagnostic procedure is often insufficient to provide a definite diagnosis. A balanced combination of different tests allows reaching a final diagnosis and drive further management.

Small bowel bleeding: cause and the role of endoscopy and medical therapy

PURPOSE OF REVIEW

The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias.

SUMMARY

SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.

Small bowel capsule endoscopy: Indications, results, and clinical benefit in a University environment

Capsule endoscopy (CE) opened a new method for visualization of the small intestine. We here further explore its clinical implications.We retrospectively analyzed the clinical benefit of CE in view of medical history, diagnostics, and therapy. Our patient collective consisted of 203 patients. CE was investigated in the context of bleeding, anemia, abdominal pain, diarrhea, Crohn's disease, and suspected tumors.The study collective consisted of 118 male and 85 female patients with a mean age of 58 years (range 8-90 years). Complete bowel transit took place in 82% of the patients. The diagnostic yield in the detection of obscure gastrointestinal bleeding was 80% and for anemia 78%. Mucosal lesions were the most common finding (43%). Unclear abdominal pain had the lowest diagnostic yield (41%). Ensuing therapeutic interventions were mostly medical (66%), and to a minor extent surgical (4.4%) as well as endoscopic (4%).In conclusion, small intestinal CE is a secure method to clarify small intestinal diseases, especially obscure gastrointestinal bleeding, even in pre-operated patients without stenosis symptoms. Our study emphasizes in a collective of patients with extensive prior diagnostics that due to CE therapeutic measures resulted in 73%.

Laparoscopic Resection of a Jejunal Inflammatory Fibroid Polyp that Caused Occult Gastrointestinal Bleeding, Diagnosed via Capsule Endoscopy and Double-Balloon Enteroscopy: A Case Report

An inflammatory fibroid polyp (IFP) is a mesenchymal tumor of the gastrointestinal tract. IFPs in the small intestine are the most frequently detected with symptoms, such as abdominal pain and tarry stool due to intussusception. Accordingly, few studies have reported jejunal IFP as a cause of occult gastrointestinal bleeding (OGIB) diagnosed via both of capsule endoscopy (CE) and double-balloon enteroscopy (DBE). A 68-year-old woman presented with a progression of anemia and a positive fecal occult blood test result. Esophagogastroduodenoscopy and total colonoscopy findings were unremarkable. CE revealed a tumor with bleeding in the jejunum. DBE also revealed a jejunal polypoid tumor. Bleeding from the tumor seemed to have caused anemia. The patient underwent partial laparoscopic resection of the jejunum, including resection of the tumor. The tumor was histopathologically diagnosed as IFP. To our knowledge, this is the first reported case of laparoscopic resection of jejunal IFP with OGIB diagnosed via CE and DBE preoperatively.

Increased Diagnostic Yield of Small Bowel Tumors with Pillcam: The Role of Capsule Endoscopy in the Diagnosis and Treatment of Gastrointestinal Stromal Tumors (GISTs). Italian Single-Center Experience

Background

Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for 1–3% of all gastrointestinal malignancies; they are, however, the most common gastric and small bowel mesenchymal tumors. The length and relative inaccessibility of the small bowel have long constrained the diagnosis of GISTs mainly presenting with chronic or intermittent bleeding as the sole clinical manifestation.

Aim

To report on the prevalence of small bowel GISTs in a prospectively recorded series of patients undergoing capsule endoscopy (CE).

Patients and methods

Between 2001 and 2007 five hundred patients were referred to our endoscopy unit for small bowel evaluation with capsule endoscopy. We retrospectively evaluated all charts. The main indications for CE were obscure-occult or obscure-overt bleeding. Two hundred eighty-nine patients underwent CE for either obscure-occult or obscure-overt bleeding and 211 for other indications. Patient outcome and care processes were measured by follow-up telephone interviews and chart review. Statistical computations were performed using Fisher's exact test and Student's t-test.

Results

CE identified a small bowel tumor in 20 patients (4.0%) and 9 tumors turned out to be GISTs (45.0%). Traditional endoscopic and radiological imaging failed to detect the GIST in all these cases. In one case a small bowel GIST was diagnosed by angiography and CE proved false negative. Overall, CE was able to diagnose a small bowel GIST in 9 out of 10 cases. All patients underwent surgical treatment and showed normalized hemoglobin levels at follow-up. The main limitation of this study is the small number of cases.

Conclusions

CE is an effective and sensitive diagnostic device compared with conventional radiology and plays an important role in the algorithm for the diagnostic work-up of suspected small bowel tumors.

Primary Jejunal Adenocarcinoma Presenting as Bilateral Ovarian Metastasis

Small intestinal tumors are rare with adenocarcinoma of the small intestine accounting for less than 2% of all gastrointestinal cancers. Primary jejunal adenocarcinoma constitutes a minute portion of small intestine adenocarcinomas. Clinically, this cancer presents at latter stages of its progression, mainly due to vague and non-specific symptoms, and the difficulty encountered in accessing the jejunum on upper endoscopy. Diagnosis of jejunal adenocarcinoma is usually inconclusive with the use of computed tomography (CT) scan, small bowel series, or upper endoscopy. Laparoscopy followed by frozen section biopsy provides a definitive diagnosis. In the past decade, balloon-assisted enteroscopy (BAE) and capsule endoscopy have become popular as useful modalities for diagnosing small bowel diseases. Wide excisional jejunectomy is the only treatment option with an estimated 5-year survival of 40-65%. Physicians are advised to suspect jejunal adenocarcinoma as a differential diagnosis in patients who present with non-specific symptoms of abdominal pain, nausea, vomiting, weight loss, anemia, gastrointestinal bleeding or signs of small bowel obstruction. We present a rare case of a 37-year-old woman with suspected bilateral ovarian masses, which was immunohistochemically confirmed as primary jejunal adenocarcinoma with bilateral ovarian metastasis.

Intraluminal rectal cancer metastasis to the small bowel: An extremely rare case report

Prolonged survival in patients suffering from colorectal cancer (CRC) may lead to the emergence of rare metastatic sites that are not well-documented in the literature. We herein describe a very rare case of an intraluminal small intestinal metastasis in a patient with previously resected CRC. A 71-year-old Caucasian male patient with a history of rectosigmoid junction cancer was initially treated with anterior resection. The tumor was classified as pT3pN0 (0/26) M0, stage II. Eighteen months after the primary surgery, local recurrence was detected in the presacral region, and the patient received combined image-guided radiotherapy and chemotherapy. Two months later, due to residual disease at the level of the anastomosis, the patient underwent additional low anterior resection with a diverting stoma. During extensive adhesiolysis, a small palpable intraluminal mass was identified in the jejunum, and segmental small bowel resection was performed. Pathological examination of the resected specimen confirmed that the lesion was a metastasis from the CRC primary. The precise mechanism and clinical significance of CRC metastasis to the small bowel remain unclear. There is limited clinical experience with this condition, as <20 cases have been reported in the literature to date. The main symptoms leading to evaluation, diagnosis and surgical resection are bowel obstruction and bleeding. The present case highlights the possibility of uncomplicated presence of metastatic CRC in the small bowel. Therefore, dilligent inspection of the peritoneal cavity, including the entire length of the gastrointestinal canal, is of paramount importance, particularly in cases of recurrent CRC.

Management of small bowel polyps: A literature review

Despite the small bowel comprising 90% of the mucosal surface area of the gastrointestinal tract, it is a rare site for neoplasia and only accounts for a little over 3% of the tumors that arise in the digestive tract. Benign small bowel lesions include lipomas, lymphangiomas, leiomyomas, neurofibromas, nodular lymphoid hyperplasia and adenomas, many of which are precursors to malignant lesions. Several polyposis syndromes are associated with small bowel polyps as well, including familial adenomatous polyposis syndrome, lynch syndrome, Peutz-Jeghers syndrome, Cowden syndrome and juvenile polyposis syndrome. Our aim was to review non-malignant small bowel polyps and discuss the prevalence, typical location, clinical presentation, diagnosis, endoscopic and histologic description and lastly management of each of these lesions.

A Prospective Blinded Comparison of Video Capsule Endoscopy Versus Computed Tomography Enterography in Potential Small Bowel Bleeding: Clinical Utility of Computed Tomography Enterography

GOALS

To compare the efficacy of video capsule endoscopy (VCE) with computed tomography enterography (CTE) in potential small bowel (SB) bleeding, and to identify factors predictive of a high diagnostic yield for CTE.

BACKGROUND

In potential SB bleeding, CTE potentially detects some lesions missed by VCE, but few data have determined its clinical utility.

STUDY

Consecutive patients with potential SB bleeding were prospectively enrolled. All underwent VCE and CTE within a 1-week interval. Definitive diagnoses were made by surgery or enteroscopy, except when a strategy of VCE and conservative management was suitable. The diagnostic yields and sensitivities of each investigation were measured.

RESULTS

Fifty-two patients were recruited (41 with overt and 11 with occult bleeding); 36 received a definitive diagnosis. The diagnostic yields and sensitivities of VCE and CTE were 59.6% and 30.8% (P=0.004), and 72.2% and 44.4% (P=0.052), respectively. The combined sensitivity of VCE and CTE (88.9%) was significantly greater than VCE (P=0.03) or CTE (P<0.01) alone. VCE was better for ulcers, enteritis, and angiodysplasia, whereas CTE was better for tumors and Meckel diverticula. Age below 40 years and severe bleeding were associated with a higher diagnostic yield for CTE [odds ratios (95% confidence interval)=7.3 (1.04-51.4), P=0.046 and 6.1 (1.4-25.5), P=0.014, respectively].

CONCLUSIONS

Both investigations complement each other in the diagnosis of potential SB bleeding. CTE should be considered when VCE is negative. Age below 40 years and severe bleeding were independent predictors of a higher diagnostic yield for CTE.