Diagnosis of small-bowel diseases in the era of capsule endoscopy

Nomenclature and Definition of Atrophic Lesions in Small Bowel Capsule Endoscopy: A Delphi Consensus Statement of the International CApsule endoscopy REsearch (I-CARE) Group

(1) Background: Villous atrophy is an indication for small bowel capsule endoscopy (SBCE). However, SBCE findings are not described uniformly and atrophic features are sometimes not recognized; (2) Methods: The Delphi technique was employed to reach agreement among a panel of SBCE experts. The nomenclature and definitions of SBCE lesions suggesting the presence of atrophy were decided in a core group of 10 experts. Four images of each lesion were chosen from a large SBCE database and agreement on the correspondence between the picture and the definition was evaluated using the Delphi method in a broadened group of 36 experts. All images corresponded to histologically proven mucosal atrophy; (3) Results: Four types of atrophic lesions were identified: mosaicism, scalloping, folds reduction, and granular mucosa. The core group succeeded in reaching agreement on the nomenclature and the descriptions of these items. Consensus in matching the agreed definitions for the proposed set of images was met for mosaicism (88.9% in the first round), scalloping (97.2% in the first round), and folds reduction (94.4% in the first round), but granular mucosa failed to achieve consensus (75.0% in the third round); (4) Conclusions: Consensus among SBCE experts on atrophic lesions was met for the first time. Mosaicism, scalloping, and folds reduction are the most reliable signs, while the description of granular mucosa remains uncertain.

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.

The role of double-balloon enteroscopy following capsule endoscopy in diagnosis of obscure Small intestinal diseases

Objective: The aim of this study was to evaluate the detection rate accuracy of Double-balloon Enteroscopy (DBE) after Capsule Endoscopy (CE) in patients with suspected small bowel diseases.

Methodology: From January 2009 to March 2012, sixty-two patients with obscure small bowel diseases who underwent CE followed by DBE were included in this study. Introduction of the endoscope by DBE was either orally or anally according to CE.

Results: Sixty-two patients are reported. The overall detection rate of small bowel diseases using CE was 70.9% (44/62). Sixty-eight DBE procedures following capsule endoscopy were carried out, There was no significant difference (χ²=0.6739, P>0.05) of Positive findings between CE and CE +DBE. Furthermore, the detection rate of small bowel diseases in patients with obscure small intestinal bleeding using CE +DBE (90.9%, 30/33) was superior to that of CE (78.8%, 26/33); χ²=1.8857, P>0.05.

Conclusions: Capsule Endoscopy (CE) can cover the whole GI tract and provide the selection of the route of Double-balloon enteroscopy (DBE). DBE can also serve as a good complementary approach after an initial imaging using CE. It can verify the findings of CE and provide therapeutic intervention. Using of CE followed by DBE is effective in the diagnosis and management of patients with obscure small bowel diseases.

Magnetic control system targeted for capsule endoscopic operations in the stomach--design, fabrication, and in vitro and ex vivo evaluations

This paper presents a novel solution of a hand-held external controller to a miniaturized capsule endoscope in the gastrointestinal (GI) tract. Traditional capsule endoscopes move passively by peristaltic wave generated in the GI tract and the gravity, which makes it impossible for endoscopists to manipulate the capsule endoscope to the diagnostic disease areas. In this study, the main objective is to present an endoscopic capsule and a magnetic field navigator (MFN) that allows endoscopists to remotely control the locomotion and viewing angle of an endoscopic capsule. The attractive merits of this study are that the maneuvering of the endoscopic capsule can be achieved by the external MFN with effectiveness, low cost, and operation safety, both from a theoretical and an experimental point of view. In order to study the magnetic interactions between the endoscopic capsule and the external MFN, a magnetic-analysis model is established for computer-based finite-element simulations. In addition, experiments are conducted to show the control effectiveness of the MFN to the endoscopic capsule. Finally, several prototype endoscopic capsules and a prototype MFN are fabricated, and their actual capabilities are experimentally assessed via in vitro and ex vivo tests using a stomach model and a resected porcine stomach, respectively. Both in vitro and ex vivo test results demonstrate great potential and practicability of achieving high-precision rotation and controllable movement of the capsule using the developed MFN.

Stereotaxis Niobe magnetic navigation system for endocardial catheter ablation and gastrointestinal capsule endoscopy

The use of robotic instruments capable of assisting medical staff during interventional or diagnostic procedures is growing rapidly today. Recently, a robotic system (Niobe, Stereotaxis Inc., USA) has been developed for navigating magnetically enabled tools inside the human body by controlling a magnetic field. This paper reports the fundamentals of this technology and reviews its application in two specific medical fields, cardiology and gastroenterology, in which its uses are different and are at dissimilar stages of development. In the first case, the system is already approved and employed for clinical treatments, such as magnetic steering of endocardial catheters for atrial fibrillation ablation, which is specifically considered in this article. In the second case, initial investigations are being performed today to study the potential magnetic maneuverability of ingestible video capsules adopted for endoscopic explorations of the digestive tract. This paper reviews current achievements and highlights future challenges related to each of these applications.

Magnetic maneuvering of endoscopic capsules by means of a robotic navigation system

The use of video capsules for noninvasive explorations of the digestive tube is progressively increasing today. At present, the motion of these wireless endoscopic devices cannot be controlled and they proceed by means of visceral peristalsis and gravity. Aimed at enabling a motion control, the technique described here uses an external magnetic field applied to the video capsule, previously coated with a magnetic shell. As a source of controlled magnetic field, a robotic magnetic navigation system, recently introduced in the clinical practice to magnetically steer cardiovascular interventional devices, was suggested in a previous study to be deserving of investigation. The attractive potentialities of this system, along with its current limitations, in order to maneuver endoscopic capsules were studied in this work for the first time, both from a theoretical and an experimental point of view. The actual capabilities were experimentally assessed with preliminary motion control tests on a conventional video capsule inside a human-sized plastic phantom. Results demonstrated the possibility of achieving controlled magnetic maneuvers within the considered environment.

A feasibility trial of computer-aided diagnosis for enteric lesions in capsule endoscopy

AIM: To investigate and evaluate the feasibility of the computer-aided screening diagnosis for enteric lesions in the capsule endoscopy (CE).

METHODS: After developing a series of algorithms for the screening diagnosis of the enteric lesions in CE based on their characteristic colors and contours, the normal and abnormal images obtained from 289 patients were respectively scanned and diagnosed by the CE readers and by the computer-aided screening for the enteric lesions with the image-processed software (IPS). The enteric lesions shown by the images included esoenteritis, mucosal ulcer and erosion, bleeding, space-occupying lesions, angioectasia, diverticula, parasites, etc. The images for the lesions or the suspected lesions confirmed by the CE readers and the computers were collected, and the effectiveness rate of the screening and the number of the scanned images were evaluated, respectively.

RESULTS: Compared with the diagnostic results obtained by the CE readers, the total effectiveness rate (sensitivity) in the screening of the commonly-encountered enteric lesions by IPS varied from 42.9% to 91.2%, with a median of 74.2%, though the specificity and the accuracy rates were still low, and the images for the rarely-encountered lesions were difficult to differentiate from the normal images. However, the number of the images screened by IPS was 5000 on average, and only 10%-15% of the original images were left behind. As a result, a large number of normal images were excluded, and the reading time decreased from 5 h to 1 h on average.

CONCLUSION: Though the total accuracy and specificity rates by the computer-aided screening for the enteric lesions with IPS are much lower than those by the CE readers, the computer-aided screening diagnosis can exclude a large number of the normal images and confine the enteric lesions to 5000 images on average, which can reduce the workload of the readers in the scanning of the images. This computer-aided screening technique can make a correct diagnosis as efficiently as possible in most of the patients.

Controlled navigation of endoscopic capsules: concept and preliminary experimental investigations

This paper describes a technique to control the navigation of traditional wireless endoscopic capsules and reports preliminary proof-of-concept investigations. These capsules are used for noninvasive explorations of the digestive tube. At present, their motion cannot be controlled and they proceed by means of the visceral peristalsis. In order to enable motion controls, the technique proposed here adopts magnetic shells which are to be applied to available capsules, immediately before their use. The shells are used to control the capsule movement by means of external magnetic fields. This solution is readily applicable to any endoscopic capsule, avoiding internal modifications. Prototype elastic shells made of silicone elastomers mixed with magnetic particles were fabricated. They were tested with the most diffused capsule (model M2A, Given Imaging Ltd., Yoqneam, Israel), by studying the performance of the capsule/shell complex in simplified experimental conditions. Bench tests permitted to demonstrate controlled translations, rotations, and rototranslations of the capsule/shell complex within tubular structures coated with pieces of bovine tissues. The use of a new instrumentation, recently developed for cardiovascular treatments, is proposed as a potential means enabling the application of controlled magnetic fields for intrabody navigations.

Recurrent abdominal pain and irritable bowel syndrome in children

PURPOSE OF REVIEW

Recurrent abdominal pain continues to be one of the most ubiquitous conditions faced by the healthcare team, and has a significant emotional and economic impact. We have moved from considering it a psychological condition to recognizing the physiological and environmental contributions, and considering the condition in the framework of a biopsychosocial model where biology, psychology and social environment interact. Here, we review current studies addressing etiologies, diagnostic techniques and treatment options for recurrent abdominal pain in children.

RECENT FINDINGS

Studies continue to highlight the role of visceral hypersensitivity in recurrent abdominal pain. The psychological state of the child and the parent (most often the mother) in terms of their anxiety, somatization and coping skills can, however, modulate the expression of symptoms. Diagnosis still is made by history and physical examination. Newer treatment options include relaxation and distraction therapies as well as medications. The role of probiotics in children remains to be defined.

SUMMARY

The approach to the child with recurrent abdominal pain must include the recognition of the physiological contributions, and this information must be relayed to the child and parents. Acknowledgement also must be paid to the role of psychological state in the parent as well as in the child in modulating the severity of symptoms.

Magnetic shells for gastrointestinal endoscopic capsules as a means to control their motion

Wireless endoscopic video capsules are becoming largely used today for non-invasive explorations of the digestive tube. Traditional types of such capsules present a major drawback: their motion can not be controlled, since they proceed by means of the visceral peristalsis only. In order to enable a wireless control of their motion, this paper describes a new concept based on the use of external magnetic fields. The proposed technique exploits magnetic shells to be applied to traditional capsules prior to their use. The shells are capable of interacting with an imposed external magnetic field, providing a means to control the capsule movement and orientation. This solution is readily and cheaply applicable to any commercial endoscopic capsule, avoiding internal modifications. The paper reports results of preliminary bench tests. Prototype elastic shells made of a silicone elastomer mixed with magnetic particles were fabricated and tested with the Given Imaging M2A capsule in simplified experimental conditions. These tests permitted to demonstrate translations, rotations and roto-translations of the capsule/shell complex onto pieces of bovine tissues.

Directive role of capsule endoscopy in determining the route for double-balloon enteroscopy

AIM: To evaluate the role of capsule endoscopy in determining the route for double-balloon enteroscopy.

METHODS: Twenty patients with negative or equivocal evaluation after capsule endoscopy received double-balloon enteroscopy (under anesthesia with propofol) by oral or anal route. The choice of the insertion route of the endoscope for the first attempt at double-balloon enteroscopy was made according to a time index (the value of the time in minutes for transit of the capsule endoscope from the pylorus to the lesion divided by the value of the time for transit of the capsule endoscope from the pylorus to the cecum). An anal route was indicated when the time index was more than 0.50. A second procedure was undertaken through the alternative route several days later when the lesion of interest was not found during the first one. The accuracy for choosing the route of double-balloon enteroscopy according to the capsule time index was then analyzed.

RESULTS: Five patients with negative evaluation after capsule endoscopy received double-balloon enteroscopy, and a lesion was detected in 1 of these patients when a second procedure by the anal route was performed. Fifteen patients with equivocal evaluation after capsule endoscopy received double-balloon enteroscopy, and the suspected findings were confirmed in 12 (80.0%) of these patients by double-balloon enteroscopy combined with pathological examination. An anal route of the endoscopy at the first attempt with double-balloon enteroscopy was selected on 4 patients (0.99, 0.8, 0.65, and 0.59, respectively), and the lesions were detected in the latter two (with a time index of 0.65 and 0.59, respectively) when a second procedure by the oral route was performed. If the time index of more than 0.75 (with consideration of another report) was used, no further attempts would be needed in these two patients, and the lesions of the other two patients were assumed to be located in the distal ileum and reached by double-balloon endoscopy via anal route exactly.

CONCLUSION: The outcome of capsule endoscopy can direct the choice of routes for double-balloon enteroscopy. A time index of more than 0.75 appears to indicate an anal route as the first procedure.

Bleeding update

Obscure bleeding is a consolidated indication to CE, which when used as a first-line exploration is the most efficient strategy as regards diagnosis in these patients. Patient selection and timing of the procedure are of paramount importance in the high diagnostic yield of CE. When integrated into a global patient care plan, CE is helpful in achieving effective decision-making concerning subsequent investigations and treatments. Although most studies appear to indicate a positive influence of CE diagnosis on clinical outcome of OGIB patients, large prospective trials are warranted to assess what is the most effective therapeutic strategy in patients with vascular lesions.