Small bowel enteroclysis with magnetic resonance imaging and computed tomography in patients with failed and uncertain passage of a patency capsule

A novel food-based negative oral contrast agent compared with two conventional oral contrast agents in abdominal CT: a three-arm parallel blinded randomised controlled single-centre trial

Background

A negative oral contrast agent (OCA) has been long sought for, to better delineate the bowel and visualise surrounding structures. Lumentin® 44 (L44) is a new OCA formulated to fill the entire small bowel. The aim of this study was to compare L44 with positive and neutral conventional OCA in abdominal computed tomography (CT).

Methods

Forty-five oncologic patients were randomised to receive either L44 or one of the two comparators (MoviPrep® or diluted Omnipaque®). Abdominal CT examinations with intravenous contrast agent were acquired according to standard protocols. The studies were read independently by two senior radiologists.

Results

The mean intraluminal Hounsfield units (HU)-values of regions-of-interest (ROIs) for each subsegment of small bowel and treatment group were -404.0 HU for L44, 166.1 HU for Omnipaque®, and 16.7 HU for MoviPrep® (L44 versus Omnipaque, p < 0.001: L44 versus MoviPrep p < 0.001; Omnipaque versus MoviPrep, p = 0.003). Adverse events, only mild, using L44 were numerically fewer than for using conventional oral contrast agents. Visualisation of abdominal structures beyond the small bowel was similar to the comparators.

Conclusions

L44 is a negative OCA with luminal radiodensity at approximately -400 HU creating a unique small bowel appearance on CT scans. The high bowel wall-to-lumen contrast may enable improved visualisation in a range of pathologic conditions. L44 showed a good safety profile and was well accepted by patients studied.

Trial registration

EudraCT (2017-002368-42) and in ClinicalTrials.gov (NCT03326518).

Supplementary Information

The online version contains supplementary material available at 10.1186/s41747-022-00267-z.

Clinical Use of Patency Capsule: A Comprehensive Review of the Literature

The patency capsule is a radiopaque, dissolvable diagnostic tool, similar in shape and size to small bowel capsule endoscopes. It was developed to offer a simple, safe, efficient, and accurate evaluation of small bowel functional patency. Although unable to provide direct visual information regarding the presence and location of strictures, masses, or luminal narrowing of the small bowel, a successful patency test minimizes the risk of retention and allows the safe administration of a capsule endoscope. However, its use entails a low risk of potentially harmful adverse events, which in their majority are indolent and resolve spontaneously. Abdominal pain and symptomatic retention are accountable for the majority of reported adverse events, whereas a limited number of reports describe life-threatening complications, namely intestinal obstruction, perforation, and intestinal ischemia. Computed tomography is the modality of choice for the identification of the exact position of an impacted patency capsule, whilst the use of plain abdominal radiographs should be avoided for the evaluation of the patency capsule position, as they provide false information. Hereby, we present a comprehensive review of the available literature regarding the characteristics, indications, clinical use, effectiveness, and adverse events of the patency capsule.10.1093/ibd/izy152_video1izy152.video15777752348001.

Is the use of AGILE patency capsule prior to videocapsule endoscopy useful in all patients with spondyloarthritis?

BACKGROUND AND AIMS

As already known, spondyloarthritis patients present a striking resemblance in intestinal inflammation with early Crohn's disease. Moreover, the frequent use of nonsteroidal anti-inflammatory drugs is an important part of their treatment. Both conditions could lead to intestinal stenoses. Therefore we proposed to investigate the usefulness of the patency capsule test in patients with spondyloarthritis.

MATERIAL AND METHODS

64 consecutive patients (33 males; mean age 38 ± 11 years) that fulfilled the AMOR criteria for seronegative spondyloarthropathy (59.4% ankylosing spondylitis) lacking symptoms or signs of intestinal stenosis were enrolled and submitted to an AGILE™ capsule patency test followed by a video capsule endoscopy (PillCam SB2™), as part of a protocol investigating the presence of intestinal inflammatory lesions. After reviewing the VCE recordings, the Lewis score (of small bowel inflammatory involvement) was computed.

RESULTS

In only 5 patients (7.8%) of the study group, the luminal patency test was negative. However, there was no retention of the videocapsule in any of the patients. From the 59 patients with a positive patency test, 3 patients presented single small bowel stenoses (two with ulcerated overlying inflamed mucosa, one cicatricial), all being traversed by the videocapsule along the length of the recording. None of the patients with a negative test had bowel stenoses. There was no correlation between the patency test and the Lewis score, the C reactive protein value, diagnosis of inflammatory bowel disease, or the family history of spondyloarthritis, psoriasis or inflammatory bowel disease.

CONCLUSION

The AGILE patency capsule does not seem to be a useful tool for all patients with spondyloarthritis prior to small bowel videocapsule endoscopy (ClinicalTrial.gov ID NCT 00768950).

Retained enteroscopy capsule in a patient with diaphragm disease

INTRODUCTION

Diaphragm disease is a rare consequence of small-bowel enteropathy, and usually occurs as a result of longstanding ingestion of non-steroidal anti-inflammatory drugs. DD is characterized by multiple strictures and saccular dilatations leading to symptoms of subacute intestinal obstruction. Often, the diagnosis is made on histological examination after laparotomy and resection of diseased small bowel.

CASE HISTORY

Here, we report a case of an elderly female who suffered for many years from chronic, colicky abdominal pain and anaemia due to undiagnosed diaphragm disease. Eventually, she was referred to our surgical team because of a retained enteroscopy capsule. The diagnosis was made after laparotomy and bowel resection. This surgical intervention alleviated chronic symptoms, and the patient remained well at 1-year follow-up.

CONCLUSIONS

This case highlights the difficulty of diagnosing diaphragm disease without laparotomy and bowel resection. A high index of suspicion must be exercised in any patient with chronic, colicky abdominal pain and anaemia together with multiple strictures and saccular dilatations on computed tomography even in the absence of longstanding NSAID ingestion. Moreover, capsule enteroscopy should be avoided as a diagnostic modality of small-bowel disease if computed tomography raises the suspicion of strictures.

Small bowel patency assessment using the patency device and a novel targeted (limited radiation) computed tomography-based protocol

BACKGROUND AND AIM

Excretion of the patency capsule (PC) within a certain time frame may be used to demonstrate luminal patency prior to capsule endoscopy (CE). We aimed to determine how often further radiological imaging is needed to confirm luminal patency after PC, assess radiologists' ability to locate the PC on plain abdominal films, and evaluate the outcomes of a novel computed tomography (CT) protocol for PC localization.

METHODS

A study of the ability of radiologists to localize PC using plain abdominal films was performed. A novel protocol targeting a limited CT at the level of the PC identified on the "scout" film if retained 30 h post-ingestion was prospectively evaluated in 400 consecutive patients undergoing PC.

RESULTS

In a study of the confidence with which radiologists could localize the PC on plain films, radiologists preferred abdominal CT to localize PCs identified on plain films in 74% of cases. In a protocol based on the use of a PC and targeted, limited CT scan to confirm small bowel patency in those failing to excrete the PC 30 h post-ingestion, the sensitivity, specificity, positive, and negative predictive value were 99.4%, 90.0%, 99.7%, and 81.0%, respectively. Crohn's disease was the only statistically significant predictor associated with higher risk of luminal stricture (P=0.001) in post-hoc analysis.

CONCLUSIONS

Excretion of the PC 30 h post-ingestion reliably predicts safe CE passage. Plain abdominal radiology is unreliable and a scout film targeted, limited CT scan offers an accurate minimal radiation method of determining small bowel patency.

Imaging modalities in pediatric inflammatory bowel disease

PURPOSE OF REVIEW

To review the various imaging modalities in the evaluation of pediatric inflammatory bowel disease (IBD) to determine disease location, clinical phenotype and the severity of disease in order to optimize treatment.

RECENT FINDINGS

Assessment of the extent, location and severity of IBD routinely involves imaging of the gastrointestinal tract. Cross-sectional modalities such as magnetic resonance enterography (MRE) and computed tomography enterography visualize the lumen, transmural involvement, extraintestinal manifestations and may facilitate decision-making in disease management. MRE has evolved as the imaging modality of choice for many pediatric IBD indications because it does not involve exposure to ionizing radiation.

SUMMARY

Advances in imaging modalities have revolutionized the assessment of children with IBD in recent years. Small-bowel follow-through is no longer considered the imaging modality of choice in this setting. Cross-sectional enterography is now preferred because, among other advantages, it can potentially distinguish active inflammation from fibrosis, characterize stricturing and penetrating complications, and diagnose extraintestinal manifestations. Although MRE avoids ionizing radiation exposure, it remains costly. Cross-sectional imaging and endoscopy complement each other in the development of objective measures for the assessment of disease activity and monitoring of response to treatment.

Clinical applications of small bowel capsule endoscopy

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

Clinical applications of small bowel capsule endoscopy

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

Utility of computed tomographic enteroclysis/enterography for the assessment of mucosal healing in Crohn's disease

Aim. When determining therapeutic strategy, it is important to diagnose small intestinal lesions in Crohn's disease (CD) precisely and to evaluate mucosal healing as well as clinical remission in CD. The purpose of this study was to compare findings from computed tomographic enteroclysis/enterography (CTE) with those from the mucosal surface and to determine whether the state of mucosal healing can be determined by CTE. Materials and Methods. Of the patients who underwent CTE for CD, 39 patients were examined whose mucosal findings could be confirmed by colonoscopy, capsule endoscopy, balloon endoscopy, or with the resected surgical specimens. Results. According to the CTE findings, patients were determined to be in the active CD group (n = 31) or inactive CD group (n = 8). The proportion of previous surgery, clinical remission, stenosis, and CDAI score all showed significant difference between groups. Mucosal findings showed an association with ulcer in 93.6% of active group patients but in only 12.5% of inactive group patients (P < 0.0001), whereas mucosal healing was found in 62.5% of inactive group patients but in only 3.2% of active group patients (P < 0.0001). Conclusion. CTE appeared to be a useful diagnostic method for assessment of mucosal healing in Crohn's disease.