Use of Capsule Small Bowel Transit Time to Determine the Optimal Enteroscopy Approach

Quality of Capsule Endoscopy Reporting in Patients Referred for Double Balloon Enteroscopy

Background

Abnormal video capsule endoscopy (VCE) findings often require intervention with double balloon enteroscopy (DBE). Accurate VCE reporting is important for procedural planning. In 2017 the American Gastroenterological Association (AGA) published a guideline that included recommended elements for VCE reporting. The aim of this study was to examine adherence to the AGA reporting guidelines for VCE.

Methods

The medical records of all patients who underwent DBE at a tertiary academic center between February 1, 2018, and July 1, 2019, were retrospectively reviewed to identify the VCE report that prompted DBE. Data were collected on the presence of each reporting element recommended by the AGA. Differences in reporting between academic and private practices were compared.

Results

A total of 129 VCE reports were reviewed (84 private practice and 45 academic practice). Reports consistently included indication, date, endoscopist, findings, diagnosis, and management recommendations. Timing of anatomic landmarks and abnormalities were included in only 87.6% of reports and preparation quality in only 26.2%. Reports from private practice groups were significantly more likely to include the type of capsule (P < 0.001). VCE reports from academic centers were more likely to include adverse outcomes (P < 0.001), pertinent negatives (P = 0.0015), extent of exam (P = 0.009), previous investigations (P = 0.045), medications (P < 0.001), and document communication to patient/referring physician (P = 0.001).

Conclusions

Most VCE reports in both private and academic settings included the important elements recommended by the AGA; however only 87% listed the times of landmarks and abnormal findings, which are crucial in determining the type and direction of approach for subsequent interventions. It is unclear whether the quality of VCE reporting influences the outcome of subsequent DBE.

Endocuff-assisted push enteroscopy increases the detection of proximal small-bowel gastrointestinal angiodysplasias

Gastrointestinal angiodysplasias (GIADs) are the most common causes for suspected small bowel bleeding. Fifty percent of GIADs do not need treatment due to bleeding cessation, while 45% have high re-bleeding rates, that significantly impact patient outcome and health resource utilization. We suspected that this high re-bleeding rate occurs because not all lesions are detected with present standard of care. This study evaluates whether device-assisted enteroscopy (DAE) utilizing the Endocuff (EC) device could improve GIAD detection. A retrospective chart review of a prospective data collection was performed from January 2006 to December 2018 at VA Loma Linda Healthcare System (VALLHCS) on both inpatients and outpatients referred for active and chronic suspected small bowel bleeding. The patients were initially monitored for bleeding lesions via video capsule endoscopy (VCE) after negative upper and lower endoscopy. GIADs observed between 0% to 40% small bowel transit time (SBTT) were referred for push enteroscopy (PE) with and without (±) the EC device. Twenty-five consecutive patients underwent PE ± EC. No patient had VCE done after PE ± EC. Using PE-EC, GIADs were detected in 9 of 25 (36%) of patients. Importantly, PE+EC detected GIADs in 23 of 25 (92%) patients. The sum of GIADs detected without EC was 26 ± 0.06 vs. 112 ± 0.2 using EC. The average detection rate for PE without EC was significantly lower (1.04 ± 0.06, mean ± SE) as compared to PE with EC (4.48 ± 0.23, mean ± SE, p<0.0005). Additionally, a positive correlation (r=0.51) between capsule enteroscopy (CE) location of GIADs and SBTT was found. The EC device increases the detection of GIADs in the proximal small bowel. We also reconfirm that the location of bleeding GIADs are within the reach of the push enteroscope (PE). Finally, PE + EC may also reduce GIAD miss rates, which may play a role in the reduction of re-bleeding episodes.

Scoring systems in clinical small-bowel capsule endoscopy: all you need to know!

Capsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2 3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4 5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.

Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8 9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.

Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.

Capsule endoscopy transit-related indicators in choosing the insertion route for double-balloon enteroscopy: a systematic review

Background and study aims  When capsule endoscopy (CE) detects a small bowel (SB) target lesion that may be manageable with enteroscopy, the selection of the insertion route is critical. Time- and progression-based CE indices have been proposed for localization of SB lesions. This systematic review analysed the role of CE transit indicators in choosing the insertion route for double-balloon enteroscopy (DBE). Methods  A comprehensive literature search identified papers assessing the role of CE on the choice of the route selection for DBE. Data on CE, criteria for route selection, and DBE success parameters were retrieved and analyzed according to the PRISMA statement. Risk of bias was assessed through the STROBE assessment. The primary outcome evaluated was DBE success rate in reaching a SB lesion, measured as the ratio of positive initial DBE to the number of total DBE. Results  Seven studies including 262 CEs requiring subsequent DBE were selected. Six studies used time-based indices and one used the PillCam Progress indicator. SB lesions were identified and insertion route was selected according to a specific cut-off, using fixed landmarks for defining SB transit except for one study in which the mouth-cecum transit was considered. DBE success rate was high in all studies, ranging from 78.3 % to 100 %. Six of seven studies were high quality. Conclusions  The precise localization of SB lesions remains an open issue, and larger studies are required to determine the most accurate index for selecting the DBE insertion route. In the future, 3 D localization technologies and tracking systems will be essential to accomplish this tricky task.