Evaluating the role of small-bowel endoscopy in clinical practice: the largest single-centre experience

Small Bowel Capsule Endoscopy: Experience from a single large tertiary care centre

Background and study aims Capsule endoscopy (CE) has transformed examination of the small bowel (SB), once considered a dark continent. The present study aimed to describe the indications, diagnostic yield, practical issues and complications of CE in one of the largest tertiary center in India. Patients and methods This retrospective analysis from a prospectively maintained database, conducted from January 2013 to June 2021 included 1155 CEs performed during this period. Patient medical records were reviewed for indications, results, and complications of CE. Results A total of 1154 patients (809 males and 345 females), mean age 53 years (range 6-87 years), one capsule got stuck in the esophagus, were included in the study. Active SB bleeding had no effect on SB transit time (324.7±161 minutes, n = 137 patients with active bleed vs 310.6±166.9 minutes, n = 1017 patients without active bleed; P = 0.35). The indication and diagnostic yield (DY) of CE were potential overt SB bleed (68.6% & 43.9%), potential occult SB bleed (8.2% and 40%), chronic diarrhea (7.9% and 28.4%), abdominal pain (6.5% and 21.3%), anemia (5.9% and 57.9%), and suspected/known case of Crohn's disease (2.3% & 56.5%) respectively. The DY for patients with age ≥60 years was similar to those with age < 60 years (61.9% vs. 51.8% respectively; P = 0.4). 21 patients (1.8%) had capsule retention of which six (0.5%) had to be referred for surgery. Conclusions CE is a safe and effective investigation with ever increasing range of indications. Potential SB bleed remains the most common indication for CE with high detection rate.

Small Bowel Refractory Bleeding: A Retrospective Study for Causes and Surgical Management

INTRODUCTION

Small bowel (SB) bleeding is one of the common gastrointestinal problems, particularly in elders. The study aimed to find the causes of refractory bleeding and overcome the challenges and difficulties of surgical treatment for SB refractory bleeding.

METHODS

All patients with SB refractory bleeding who underwent surgical treatment were included in this study. Patients' characteristics, surgical finding, and follow-up assessments were reviewed and analyzed through Hospital Information System records from October 1, 2014, to November 30, 2020. All analyses were performed using SPSS v23.0.

RESULTS

The causes of SB bleeding include vascular lesions (angioectasia, arteriovenous malformations, and dieulafoy lesions) 29.6%, tumors (Polyps, gastrointestinal stromal tumor, Adenocarcinoma, and other) 24.5%, diverticular 18.4%, ulcers/erosion 15.3%, inflammatory bowel disease 7.1%, and other 5.1%. Patients (age below 60 y) were highly developed SB bleeding caused by diverticular 26.4% compared with patients (age 60 y or older) 8.9%, whereas bleeding caused by vascular lesions was significantly higher in patients (age 60 y or older) 37.8%. Other causes, such as tumors and inflammatory bowel disease, showed no significant difference related in age. Exploratory laparotomy was the standard method of bowel extrinsic examination. The intraoperative enteroscopy enterotomy (IOE-E) and IOE-combined were performed in 52 patients (1:1). IOE-E shows lower postoperative morbidity and shorter time of operation P <0.05 compared with the IOE-combined approach.

CONCLUSIONS

Age and exhaustive patient history can assist in finding out the etiology. IOE-E is safe, and coordination between surgeon and endoscopist is necessary for IOE if an identifiable source cannot be found in endoscopy or exploratory laparotomy alone.

Octa-nonagenarians can perform video capsule endoscopy safely and with a higher diagnostic yield than 65-79-year-old patients

BACKGROUND

Video capsule endoscopy (VCE) is an effective, noninvasive modality for small bowel (SB) investigation. Its usage in the older adults is rising. However, data in octa-nonagenarians regarding diagnostic yield and motility are lacking. Our aim was to evaluate and compare safety and efficacy of VCE between age subgroups of older adult patients.

METHODS

This was a retrospective study of prospectively documented data. All consecutive VCEs of patients ≥65 years (01/2010-12/2017) were included. Patients unable to swallow the capsule or videos with significant recording technical malfunction were excluded. The cohort was divided into the younger group aged 65-79 years old and octa-nonagenarians aged ≥80 years old. Indications for referral, diagnostic yield and transit times were compared between groups.

RESULTS

A total of 535 VCEs were performed in 499 older adult patients (51.2% males); 82.8% were 65-79 years old and 17.2% were ≥80 years old. The ≥80-year-old group had higher rates of clinically significant findings (52.7% vs. 40.0%, p = 0.025), active bleeding (12.5% vs. 6.5%, p = 0.053) and angioectasia (36.0% vs. 23.4%, p = 0.014). Crohn's disease was newly diagnosed in approximately 8% of the entire cohort and 12% of the ≥80 years old. Anemia was the most common indication in both groups, followed by overt bleeding in the ≥80-year-old group (25% vs. 9.9% in 65-79-year-old group, p < 0.001) and Crohn's disease in the 65-79 years old (17.2% vs. 5.4% in ≥80 years old, p = 0.004). Groups were comparable in transit time and cecal documentation rates.

CONCLUSIONS

In octa-nonagenarians, VCE is as safe as in younger older-adults with a higher diagnostic yield of significant and treatable conditions.

Small bowel enteroscopy - A joint clinical guideline by the Spanish and Portuguese small-bowel study groups

The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small-bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication, and its diagnostic and therapeutic yield. A set of recommendations was issued accordingly.

Laparoscopic assisted balloon enteroscopy to detect obscure gastrointestinal bleeding sources missed by capsule endoscopy

Jejunoileal neuroendocrine tumours (NETs) are frequently multifocal and represent a consistent source of obscure gastrointestinal bleeding (OGIB). We report the real-life case of a female presenting to our attention for severe episodes of haematochezia caused by multiple localisation of jejunoileal NETs. A discrepancy between pre-operative total body contrast-enhancement computed tomography scan and capsule endoscopy (CE) emerged, in terms of numbers of lesions, so that, as completeness, an intraoperative balloon-assisted enteroscopy (BAE) was carried out, leading to the detection of the multiple lesions missed during CE. In case of obscure gastrointestinal bleeding sources missed by capsule endoscopy, laparoscopic-assisted balloon enteroscopy plays an essential role, allowing both to assess a precise diagnosis and to resect the intestinal bleeding tract.

Artificial Intelligence in Small Bowel Endoscopy: Current Perspectives and Future Directions

Artificial intelligence (AI) is a computer system that is able to perform tasks which normally require human intelligence. The role of AI in the field of gastroenterology has been gradually evolving since its inception in the 1950s. Discovery of wireless capsule endoscopy (WCE) and balloon enteroscopy (BE) has revolutionized small gut imaging. While WCE is a relatively patient-friendly and noninvasive mode to examine the nonobstructed small gut, it is limited by a lengthy examination time and the need for expertise in reading images acquired by the capsule. Similarly, BE, despite having the advantage of therapeutic intervention, is costly, invasive, and requires general sedation. Incorporation of concepts like machine learning and deep learning has been used to handle large amounts of data and images in gastroenterology. Interestingly, in small gut imaging, the application of AI has been limited to WCE only. This review was planned to examine and summarize available published data on various AI-based approaches applied to small bowel disease.

We conducted an extensive literature search using Google search engine, Google Scholar, and PubMed database for published literature in English on the application of different AI techniques in small bowel endoscopy, and have summarized the outcome and benefits of these applications of AI in small bowel endoscopy. Incorporation of AI in WCE has resulted in significant advancements in the detection of various lesions starting from dysplastic mucosa, inflammatory and nonmalignant lesions to the detection of bleeding with increasing accuracy and has shortened the lengthy review time in image analysis. As most of the studies to evaluate AI are retrospective, the presence of inherent selection bias cannot be excluded. Besides, the interpretability (black-box nature) of AI models remains a cause for concern. Finally, issues related to medical ethics and AI need to be judiciously addressed to enable its seamless use in future.

What is the effective clinical use of small bowel capsule endoscopy in real life?

Capsule endoscopy is a noninvasive and easy method for evaluating the gastrointestinal tract. Since the wireless capsule endoscopy system was first developed, many new technical improvements have been made in order to gain maximum benefit from the procedure. However, at this stage, it remains a diagnostic modality, the main indication for its use being obscure gastrointestinal bleeding. Capsule endoscopy is only contraindicated in symptomatic intestinal obstruction. New indications for use and therapeutic options may become possible with the further development of nanotechnologies.

Small Bowel Enteroscopy - A Joint Clinical Guideline from the Spanish and Portuguese Small Bowel Study Groups

The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication and on its diagnostic and therapeutic yields. A set of recommendations were issued accordingly.

Validity of Capsule Endoscopy in Monitoring Therapeutic Interventions in Patients with Crohn's Disease

Mucosal healing in Crohn’s disease (CD) can be evaluated by capsule endoscopy (CE). However, only a few studies have utilized CE to demonstrate the therapeutic effect of medical treatment. We sought to evaluate the validity of using CE to monitor the effect of medical treatment in patients with CD. One hundred (n = 100) patients with CD were enrolled. All patients had a gastrointestinal (GI) tract patency check prior to CE. Patients with baseline CE Lewis score (LS) ≤ 135 were included in the non-active CD group and ended the study. In those with LS > 135 (active CD group), additional treatment was administered, regardless of symptoms, as per the treating clinician’s advice. Patients of the active CD group underwent follow-up CE assessment 6 months later. Out of 92 patients with confirmed GI patency who underwent CE, 40 (43.4%) had CE findings of active inflammation. Of 29 patients with LS > 135 who received additional medications and underwent follow-up CE, improvement of the LS was noted in 23 (79.3%) patients. Eleven patients were asymptomatic but received additional medications; 8 (72.7%) had improvement of the LS. This study demonstrated that additional treatment even for patients with CD in clinical remission and active small-bowel inflammation on CE can reduce mucosal damage.

Paradigm shift: should the elderly undergo propofol sedation for DBE? A prospective cohort study

OBJECTIVE

Evaluate the safety of propofol-assisted double balloon enteroscopy (DBE) in elderly patients against a younger cohort.

DESIGN

Prospective cohort study.

SETTING

All patients undergoing DBE over a 30-month period were recruited at our tertiary centre.

PATIENTS

215 procedures in 161 patients were performed. An age cut-off of 65 years and above was used to define those who were elderly.

INTERVENTIONS

Patients were subcategorised into four groups: elderly or young undergoing DBE with propofol or conventional sedation (with midazolam±fentanyl).

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, procedural data, complications, diagnostic and therapeutic yield were compared.

RESULTS

Cardiovascular disease and a higher American Society of Anaethesiologists (ASA) status were more prevalent in elderly patients undergoing DBE with propofol (p<0.05). Common indications for DBE were occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease (elderly vs young: 50.7% vs 42.3%, 17.8% vs 12% and 19.2% vs 26.1%, respectively). Diagnostic yield was higher in elderly compared with young patients (75.3% vs 58.5%, p=0.016). The most common findings in elderly and young patients were angioectasia (30.1% and. 18.3%, respectively) and ulcers (17.8% and 9.2%, respectively), while therapeutic intervention rates were comparable (42.5% vs 32.4%, p=0.18). ASA status did not affect propofol dose (p=0.55) or procedure duration (p=0.31). Tolerance scores were favourable in those receiving propofol compared with conventional sedation (p<0.05). There was no difference in complications between the four groups (p=0.17).

CONCLUSION

Compared with young patients, propofol-assisted DBE in the elderly is safe and has a high diagnostic yield.

Neoplastic Diseases of the Small Bowel

The incidence of small bowel tumors is increasing over time. Until recently, their diagnosis was delayed and it was often reached only at the time of surgery. New diagnostic tools, such as capsule endoscopy, device-assisted enteroscopy, and dedicated small bowel cross-sectional imaging techniques, have been introduced recently in clinical practice. The combination of these tools allows medical practitioners to detect small bowel tumors at an early stage and to reach a definite diagnosis before surgery, thus enabling minimally invasive treatments.

Capsule endoscopy and single-balloon enteroscopy in small bowel diseases: Competing or complementary?

AIM

To evaluate diagnostic yields of capsule endoscopy (CE) and/or single-balloon enteroscopy (SBE) in patients with suspected small bowel diseases.

METHODS

We retrospectively analyzed 700 patients with suspected small bowel diseases from September 2010 to March 2016. CE, SBE, or SBE with prior CE was performed in 401, 353, and 47 patients, respectively. Data from clinical and endoscopy records were collected for analysis. Indications, procedure times, diagnostic yields, and complications were summarized and evaluated.

RESULTS

The overall diagnostic yield for the CE group was 57.6%. The diagnostic yield of CE in patients with obscure gastrointestinal bleeding (OGIB) was significantly greater than that in patients with no bleeding (70.5% vs 43.8%, P < 0.01). The overall diagnostic yield of SBE was 69.7%. There was no difference in the diagnostic yield of SBE between patients with OGIB and those with no bleeding (72.5% vs 68.9%, P = 0.534). Forty-seven patients underwent CE prior to SBE. Among them, the diagnostic yield of SBE with positive findings on prior CE was 93.3%. In addition, SBE detected two cases with superficial ulcer and erosive lesions in the small bowel, which were missed by CE. However, one case with lymphoma and two with Crohn’s disease were not confirmed by SBE. The rate of capsule retention was 2.0%. There were no significant complications during or after SBE examinations.

CONCLUSION

SBE is a safe and effective technique for diagnosing small bowel diseases. SBE with prior CE seemed to improve the diagnostic yield of small bowel diseases.

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

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

Endoscopy in the Diagnosis and Management of Complications of Inflammatory Bowel Disease

The role of endoscopy in inflammatory bowel disease (IBD) has grown over the last decade in both diagnostic and therapeutic realms. It aids in the initial diagnosis of the disease and also in the assessment of the extent and severity of disease. IBD is associated with development of multiple complications such as strictures, fistulae, and colon cancers. Endoscopy plays a pivotal role in the diagnosis of colon cancer in patients with IBD through incorporation of chromoendoscopy for surveillance. In addition, endoscopic resection with surveillance is recommended in the management of polypoid dysplastic lesions without flat dysplasia. IBD-associated benign strictures with obstructive symptoms amenable to endoscopic intervention can be managed with endoscopic balloon dilation both in the colon and small intestine. In addition, endoscopy plays a major role in assessing the neoterminal ileum after surgery to risk-stratify patients after ileocolonic resection and assessment of a patient with ileoanal pouch anastomosis surgery and management of postsurgical complications. Our article summarizes the current evidence in the role of endoscopy in the diagnosis and management of complications of IBD.

Celiac Disease and Double-Balloon Enteroscopy: What Can We Achieve?: The Experience of 2 European Tertiary Referral Centers

BACKGROUND

Indications to double-balloon enteroscopy (DBE) are not standardized in celiac disease (CD).

GOALS

To evaluate the clinical usefulness of DBE in complicated CD.

STUDY

DBE findings in celiac patients with suspected small bowel (SB) complications were retrospectively evaluated in 2 tertiary referral centers (Milan and Sheffield). Demographic data of the studied cohort were compared with a database of 1000 noncomplicated CD patients.

RESULTS

Twenty-four CD cases (12 males, P=0.01 vs. controls) were reviewed. Mean age at CD diagnosis (y±SD) was 37±20 versus 27±18 and at SB evaluation 47±15 versus 38±13 (P<0.01 compared with controls). Indications for DBE were refractory CD (#9), gastrointestinal symptoms (#6), severe iron-deficiency anemia (#6), and long standing poor dietary adherence (#3). Two jejunal adenocarcinomas and an ileal neuroendocrine tumor were detected in presence of iron-deficiency anemia. Three type I and 3 type II refractory CD patients showed jejunal ulcerations; 2 of type II presented small white raised patches. Patchy atrophy was observed in nonadherent patients and in 2 on a gluten-free diet for a short time. Therapy was planned in 33% of patients after DBE. No adverse events were detected at follow-up [21 mo (range, 0 to 60 mo)].

CONCLUSIONS

This is the largest international study on the outcomes of DBE in CD demonstrating its usefulness to exclude/confirm malignant or premalignant conditions, associated with even minor lesions. Studies are needed to understand the clinical relevance of the SB endoscopic features and to optimize DBE indications.

Is capsule endoscopy appropriate for elderly patients? The influence of ageing on findings and diagnostic yield: An Italian retrospective study

BACKGROUND

Few data are available on the use of capsule endoscopy in the elderly.

METHODS

We performed a retrospective study on 1008 consecutive patients referred to our centre between December 1, 2002 and January 30, 2014 who underwent capsule endoscopy for various indications. Patients were enrolled and divided into 3 sub-groups according to their age (Group A: <50 years; Group B: 50-69 years; Group C: >70 years). The Pillcam diagnostic yield, clinically significant findings and post-treatment outcomes were compared between groups.

RESULTS

Diagnostic yield was significantly higher in Group C vs. Groups A and B (65.2% vs. 42.3% and 47.5%, respectively; p<0.05). The most common diagnosis in the elderly was angiodysplasia (42.5%). In 84.5% of elderly patients (Group C) capsule endoscopy results modified patient management.

CONCLUSIONS

Capsule endoscopy has a high diagnostic yield and positive impact on management in patients aged >70 years.

Capsule endoscopy followed by single balloon enteroscopy in children with obscure gastrointestinal bleeding: a combined approach

BACKGROUND

This prospective single-centre study aims to evaluate a new diagnostic algorithm using capsule endoscopy, colon capsule endoscopy and single-balloon enteroscopy in the work-up of obscure gastrointestinal bleeding in children.

METHODS

The usefulness of a new diagnostic algorithm was assessed comparing the clinically relevant findings revealed by each technique, and evaluating the clinical outcomes during the follow-up.

RESULTS

A total of 22 paediatric patients were evaluated (14 male; mean age 12.5 years ± 3.9). Capsule endoscopies were positive in 14 (63.6%), suspicious in 5 (22.7%) and negative in 3 (13.6%). A second look with colon capsule identified new lesions in 2/3 (67%) of previous negative cases. Enteroscopies were able to reach the positive and suspicious findings in all but 2, in which an intraoperative enteroscopy was needed. This combined approach showed positive findings in 21/22 of cases with a diagnostic yield of 95%. Eighteen patients (82%) had a complete resolution after therapy. One patient resolved his symptoms spontaneously. Despite diagnosis, in three patients (13.6%) the gastrointestinal bleeding was not resolved after therapy.

CONCLUSION

This algorithm achieves optimal levels of diagnostic yield (95%) and therapeutic outcome (82%). This approach deserves to be studied in a larger multicentre cohort of patients and for a longer follow-up period.

Blue mode imaging may improve the detection and visualization of small-bowel lesions: A capsule endoscopy study

BACKGROUND/AIMS

Diagnostic miss rate and time consumption are the two challenging limitations of small-bowel capsule endoscopy (SBCE). In this study, we aimed to know whether using of the blue mode (BM) combined with QuickView (QV) at a high reviewing speed could influence SBCE interpretation and accuracy.

MATERIALS AND METHODS

Seventy CE procedures were totally reviewed in four different ways; (1) using the conventional white light, (2) using the BM, [on a viewing speed at 10 frames per second (fps)], (3) using white light, and (4) using the BM (on a viewing speed at 20 fps). In study A, the results of (1) were compared with those of (2), and in study B, the results of (3) and (4) were separately compared with those of (1).

RESULTS

In study A, the total number of the vascular (P < 0.001) and the inflammatory lesions (P = 0.005) detected by BM was significantly higher than that detected by the white light. No lesion was found using the white light that was not detected by the BM. Moreover, the BM highly improved the image quality of all the vascular lesions and the erythematous ones from the nonvascular lesions. In study B, the total number of only the vascular lesions, detected by the BM on a rapid speed of viewing at 20 fps was significantly higher than that detected by the white light (P = 0.035). However, the true miss rate for the BM was 4%.

CONCLUSION

BM imaging is a new method that improved the detection and visualization of the vascular and erythematous nonvascular lesions of SB as compared with the conventional white light imaging. Using of the BM at a slow viewing speed, markedly reduced the diagnostic miss rate of CE.

Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature

Iron deficiency anemia (IDA) is common and often under recognized problem in the elderly. It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract. Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel (SB). Capsule endoscopy (CE) provides direct visualization of entire SB mucosa, which was not possible before. It is superior to push enteroscopy, enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA. Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA. The diagnostic yield of CE for IDA progressively increases with advancing age, and is highest among patients over 85 years of age. Balloon assisted enteroscopy is used to treat the lesions seen on CE. CE has some limitations mainly lack of therapeutic capability, inability to provide precise location of the lesion and false positive results. Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.

Small bowel bleeding: a comprehensive review

The small intestine is an uncommon site of gastro-intestinal (GI) bleeding; however it is the commonest cause of obscure GI bleeding. It may require multiple blood transfusions, diagnostic procedures and repeated hospitalizations. Angiodysplasia is the commonest cause of obscure GI bleeding, particularly in the elderly. Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients. Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds. Deep enteroscopy has also an added advantage of therapeutic potential. Computed tomography is helpful in identifying extra-intestinal lesions. In cases of difficult diagnosis, surgery and intra-operative enteroscopy can help with diagnosis and management. The treatment is dependent upon the aetiology of the bleed. An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy. Small bowel bleeding can be managed by conservative, radiological, pharmacological, endoscopic and surgical methods, depending upon indications, expertise and availability. Some patients, especially those with multiple vascular lesions, can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.

Double-balloon enteroscopy in Ireland in the capsule endoscopy era

BACKGROUND

The availability of double-balloon enteroscopy (DBE) and small bowel capsule endoscopy (SBCE) in Ireland has revolutionised our approach to the diagnosis and treatment of small bowel disorders.

AIMS

To evaluate the use of DBE in Ireland and to compare the diagnostic yield with and without prior SBCE in order to improve the efficiency of our resources for small bowel endoscopy.

METHODS

A retrospective comparison study of all DBEs performed between two centres, one with SBCE available, was undertaken. Information was obtained by review of endoscopy reports, referral letters, radiology reports and charts. A review of the SBCE database was undertaken to identify patients who had undergone SBCE prior to DBE.

RESULTS

A total of 242 DBE procedures were carried out between both centres. SBCE was performed prior to DBE in 20 % (n = 46). The overall diagnostic yield of DBE was 47 % (n = 115). There was a statistically significant difference in diagnostic yield between the DBE only and the DBE with prior SBCE groups 44 versus 61 %, respectively, p < 0.0001. There was also a significant difference in the DBE approach, with 73 % of procedures being anterograde in centre 1 versus 56 % in centre 2. A subgroup analysis of centre 1 data revealed a negative predictive value of 100 % and a positive predictive value of 74 % for SBCE when DBE findings were considered as a gold standard.

CONCLUSION

SBCE as a screening tool prior to DBE is extremely valuable and increases the diagnostic yield considerably as a consequence of a high negative predictive value.

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.

Enteroscopy in small bowel Crohn’s disease: A review

Crohn’s disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in inflammation, stricturing and fistulae secondary to transmural inflammation. Diagnosis relies on clinical history, abnormal laboratory parameters, characteristic radiologic and endoscopic changes within the gastrointestinal tract and most importantly a supportive histology. The article is intended mainly for the general gastroenterologist and for other interested physicians. Management of small bowel CD has been suboptimal and limited due to the inaccessibility of the small bowel. Enteroscopy has had a significant renaissance recently, thereby extending the reach of the endoscopist, aiding diagnosis and enabling therapeutic interventions in the small bowel. Radiologic imaging is used as the first line modality to visualise the small bowel. If the clinical suspicion is high, wireless capsule endoscopy (WCE) is used to rule out superficial and early disease, despite the above investigations being normal. This is followed by push enteroscopy or device assisted enteroscopy (DAE) as is appropriate. This approach has been found to be the most cost effective and least invasive. DAE includes balloon-assisted enteroscopy, [double balloon enteroscopy (DBE), single balloon enteroscopy (SBE) and more recently spiral enteroscopy (SE)]. This review is not going to cover the various other indications of enteroscopy, radiological small bowel investigations nor WCE and limited only to enteroscopy in small bowel Crohn’s. These excluded topics already have comprehensive reviews. Evidence available from randomized controlled trials comparing the various modalities is limited and at best regarded as Grade C or D (based on expert opinion). The evidence suggests that all three DAE modalities have comparable insertion depths, diagnostic and therapeutic efficacies and complication rates, though most favour DBE due to higher rates of total enteroscopy. SE is quicker than DBE, but lower complete enteroscopy rates. SBE has quicker procedural times and is evolving but the least available DAE today. Larger prospective randomised controlled trial’s in the future could help us understand some unanswered areas including the role of BAE in small bowel screening and comparative studies between the main types of enteroscopy in small bowel CD.

The use of small bowel capsule endoscopy in iron deficiency anaemia: low impact on outcome in the medium term despite high diagnostic yield

INTRODUCTION

Small bowel capsule endoscopy (SBCE) is a useful diagnostic modality in small bowel disorders. Iron deficiency anaemia (IDA) is one of the most common indications for SBCE. However, there are limited data on the diagnostic yield for IDA alone, and little is known about the clinical impact and long-term outcome of patients following SBCE.

AIM

To determine the diagnostic yield of SBCE in IDA and to examine outcome.

MATERIALS AND METHODS

A retrospective review of a tertiary referral centre's database over a 21-month time period was carried out. Information on follow-up and management was obtained through chart review.

RESULTS

In all, 309 SBCEs were identified, 30% (n=93) for anaemia and in 70% (n=65), follow-up data were available. The small bowel diagnostic yield for IDA was 53% (n=35), including angiodysplasia 49% (n=17), nonspecific inflammation 34% (n=12), active bleeding 11% (n=4) and Crohn's disease 6% (n=2). In addition, 16% (n=10) had abnormalities (gastritis, gastric antral vascular ectasia, duodenitis) outside the small bowel. In all, 42% (n=27) were persistently anaemic after a mean follow-up of 9.3 months. Of these, 52% (n=14) and 48% (n=13) had positive and negative SBCEs, respectively. In total, SBCE led to a change in treatment in 28 patients (44%), of whom 17 (61%) remained anaemic.

CONCLUSION

This study shows a high overall diagnostic yield for SBCE in IDA 71% (n=45). Despite the majority, 53% (n=24), of patients with positive tests receiving specific treatment, 61% (n=17) remained anaemic in the long term. SBCE results were not predictive of long-term outcome even when stratified for a change in management.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENTS

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

INTERVENTION

CE.

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

LIMITATIONS

Single center.

CONCLUSION

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

QuickView in small-bowel capsule endoscopy is useful in certain clinical settings, but QuickView with Blue Mode is of no additional benefit

BACKGROUND

Analysis of small-bowel capsule endoscopy (SBCE) is time-consuming. QuickView (QV) has been added to the RAPID software to reduce the reading times. However, its validity is still under intense review. Recently, we have shown that Blue Mode (BM) provides improvements in images for most lesion categories.

AIM

To assess the validity of QuickView with white light (QVWL) and QuickView with Blue Mode (QVBM) reading, in a group of patients who underwent SBCE in our centre, by comparing it with the standard video sequence review (used as reference) by experienced SBCE readers.

METHODS

This was a retrospective study; all SBCE (August 2008-November 2011), performed with PillCam SB, with complete small-bowel visualization were included. A clinician with previous SBCE experience, unaware of the SBCE reports, reviewed prospectively the video streams on RAPID platform using QVWL and QVBM. All SBCE had been reported previously using the standard mode; these reports were considered as the reference. There were 106 cases of obscure gastrointestinal bleeding (OGIB), 81 cases of known or suspected Crohn's disease (CD) and 10 cases of polyposis syndromes.

RESULTS

The mean small-bowel evaluation was 475 (± 270) s and 450 (± 156) s for QVWL and QVBM, respectively. In the OGIB (n=106; 21 overt/85 occult), with QVWL, 54 [P0 (28), P1 (18), P2 (8)] lesions were detected, 63 [P0 (48), P1 (13), P2 (2)] with QVBM, as compared with 98 [P0 (67), P1 (23), P2 (8)] by standard (reference) reporting. For P1+P2 lesions, the sensitivity, specificity, positive predictive value and negative predictive value for QVWL (as compared with reference reporting) were 92.3, 96.3, 96 and 92.8%, respectively. For QVBM, the above values were 91, 96, 96.2 and 90.6%, respectively. Eighty-one (n=81) patients underwent SBCE for small-bowel evaluation on the basis of a clinical history of suspected or known CD. With QVWL, 71 mucosal ulcers were detected, 68 with QVBM, as compared with 155 mucosal ulcers with reference reading. Finally, in the polyposis category with QVWL and QVBM, four polypoid lesions were detected compared with seven with standard (reference) review.

CONCLUSION

QV can be used confidently in OGIB in an urgent inpatient setting and in outpatients with occult OGIB or suspected CD. Furthermore, BM does not confer any additional advantage in the QV setting. Standard review settings should be used in all other cases.