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

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.

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.

Intraoperative push enteroscopy for treatment of occult small bowel bleed due to hemorrhagic bleed and tumor: a report of two cases

Small bowel bleeds, while uncommon, are often challenging with regard to diagnosis and therapeutic intervention. This is primarily due to their occult nature, the location offending lesions and limitations of current technology used to assess them. This review highlights two patients who presented with signs and symptoms of a small bowel bleed, where initial diagnostic workups were inconclusive, and intraoperative enteroscopy served a diagnostic and therapeutic role. We discuss the current literature on intraoperative endoscopy and propose an algorithm that introduces intraoperative enteroscopy earlier as a viable curative option, particularly in a rural setting. This case series proposes considerations for earlier introduction of intraoperative enteroscopy for diagnosis and treatment of small bowel bleeds.

Cancer risk in patients with Peutz-Jeghers syndrome in Korea: a retrospective multi-center study

BACKGROUND/AIMS

There have been little research on the cancer risks of patients with Peutz-Jeghers syndrome (PJS) in Korea. We aimed to investigate the clinical features of PJS patients and their cancer incidence rate.

METHODS

Patients with PJS from nine medical centers were enrolled. In those patients diagnosed with cancer, data obtained included the date of cancer diagnosis, the tumor location, and the cancer stage. The cumulative risks of gastrointestinal cancers and extra-gastrointestinal cancers were calculated using the Kaplan-Meier method.

RESULTS

A total of 96 PJS patients were included. The median age at diagnosis of PJS was 23.4 years. Cancer developed in 21 of the 96 patients (21.9%). The age of PJS diagnosis was widely distributed (0.9 to 72.4 years). The most common cancers were gastrointestinal cancer (n = 12) followed by breast cancer (n = 6). The cumulative lifetime cancer risk was calculated to be 62.1% at age 60. The cumulative lifetime gastrointestinal cancer risk was 47.1% at age 70. The cumulative lifetime extra- gastrointestinal cancer risk was 40.3% at age 60.

CONCLUSION

PJS onset may occur at any age and the risks of gastrointestinal and extra-gastrointestinal cancer are high. Thorough surveillance of PJS patients for malignancies is vital.

Application of capsule endoscopy in patients with chronic and recurrent abdominal pain: Abbreviated running title: capsule endoscopy in abdominal pain

OBJECTIVE

The incidence of chronic and recurrent abdominal pain increases every year, while the diagnosis is still unsatisfactory even after a number of check-ups. This study aimed to evaluate the diagnosis value of capsule endoscopy in patients suffering from chronic and recurrent abdominal pain.

METHODS

A retrospective case study was performed in 80 chronic and recurrent abdominal pain patients at Xiangyang Central Hospital from January 2013 to November 2017. Meanwhile, diagnoses by capsule endoscopy were collected for analysis.

RESULTS

Abnormal findings were found in 54 of 80 (67.5%) patients. The findings in chronic and recurrent abdominal pain patients include small intestinal erosion and congestion, small intestinal ulcers, small intestinal parasites, small intestinal vascular malformations, small intestinal polyps, small intestinal diverticulum, and small intestinal lymphangiectasia. There were no immediate significant side effects without being reported up to 1 month after ingestion of the capsule. The capsule was evacuated by all patients.

CONCLUSIONS

Capsule endoscopy has a great value in the diagnosis of chronic and recurrent abdominal pain with satisfactory safety and less pain for patients. Inflammatory lesions and ulcers in the small intestine account for the majority of positive findings in these patients.

Recent developments in small bowel endoscopy: the "black box" is now open!

Over the last few years, capsule endoscopy has been established as a fundamental device in the practicing gastroenterologist’s toolbox. Its utilization in diagnostic algorithms for suspected small bowel bleeding, Crohn’s disease, and small bowel tumors has been approved by several guidelines. The advent of double-balloon enteroscopy has significantly increased the therapeutic possibilities and release of multiple devices (single-balloon enteroscopy and spiral enteroscopy) aimed at improving the performance of small bowel enteroscopy. Recently, some important innovations have appeared in the small bowel endoscopy scene, providing further improvement to its evolution. Artificial intelligence in capsule endoscopy should increase diagnostic accuracy and reading efficiency, and the introduction of motorized spiral enteroscopy into clinical practice could also improve the therapeutic yield. This review focuses on the most recent studies on artificial-intelligence-assisted capsule endoscopy and motorized spiral enteroscopy.

Epidemiology, Risk Factors and Diagnosis of Small Bowel Adenocarcinoma

Simple Summary

Small bowel adenocarcinoma is a rare tumor. Diagnosis is often obtained at an advanced stage and prognosis remains poor. The aim of this review is to report the recent epidemiological and risk factor data related to small bowel adenocarcinoma. New diagnostic tools are also described in this review.

Abstract

Adenocarcinomas of the small intestine are rare tumors but their incidence is increasing. There is a slight male predominance. The median age at diagnosis is the 6th decade. The most frequent primary location is the duodenum. There is no clearly identified environmental risk factor, but adenocarcinomas of the small intestine are associated in almost 20% of cases with predisposing diseases (Crohn’s disease, Lynch syndrome, familial adenomatous polyposis, Peutz–Jeghers syndrome and celiac disease).

Small bowel lymphoma: clinical update and challenges for the gastroenterologist

PURPOSE OF REVIEW

The diagnosis of small bowel lymphoma (SBL) can be challenging, as they are very rare and also have a varied presentation. In this review, we aim to provide a broad overview of the types of SBL and also about the various modalities used for their diagnosis. We also discuss the overview of treatment strategies for a gastroenterologist.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) and devise-assisted enteroscopy (DAE) has revolutionized the way we investigate the small bowel. DAE also makes it possible to obtain histological samples for further characterization of SBL. This has led to a significant improvement in diagnosis and management of the disease in conjunction with cross-sectional imagining.

SUMMARY

The diagnosis and management of small bowel lymphoma remains challenging despite the development of newer techniques such as SBCE and DAE. The current available diagnostic modalities have limitations; in the absence of a gold standard, the current investigative modalities compliment each other in reaching the final diagnosis.

Small Bowel Malignancies in Patients Undergoing Capsule Endoscopy for Iron Deficiency Anemia

Small bowel malignancies are rare and usually asymptomatic or symptoms are nonspecific. Therefore, small bowel tumors are difficult to diagnose. In patients with iron deficiency anemia (IDA) who have negative bidirectional endoscopy results, the small bowel may be considered the source of bleeding. However, in asymptomatic IDA patients with negative bidirectional endoscopy results, evidence supporting the routine use of capsule endoscopy (CE) is insufficient. CE can be considered in selected patients with recurrent or persistent IDA. The frequency of small bowel malignancies is low in patients undergoing CE for IDA, but the usefulness of CE for the diagnosis of small bowel malignancies in younger age groups with IDA has been reported. For patients with risk factors for small bowel malignancy, investigation of the small bowel should be considered. Efforts should be made to prevent adverse events, such as capsule retention or capsule aspiration, through meticulous history taking and endoscopic capsule delivery as necessary.

Peutz-Jeghers syndrome

PURPOSE OF REVIEW

Peutz-Jeghers syndrome is a rare, autosomal dominant, hereditary polyposis syndrome defined by gastrointestinal hamartomas and mucocutaneous pigmentations, caused by a germline mutation in the serine/ threonine kinase 11 or liver kinase B1 (STK11/LKB1) genes. Hamartomatous polyps located throughout the gastrointestinal tract can be complicated by bleeding and small bowel intussusception, potentially leading to the need for emergency surgery. Individuals suffering from Peutz-Jeghers syndrome have an increased lifetime risk of various forms of cancer (gastrointestinal, pancreatic, lung, breast, uterine, ovarian and testicular). Surveillance should lead to the prevention of complications and thus a reduction in mortality and morbidity of patients.

RECENT FINDINGS

A combined approach based on wireless capsule endoscopy, magnetic resonance enterography and device-assisted enteroscopy is effective in reduction of the polyp burden and thus decreasing the risk of bleeding and intussusception. Current guidelines for screening and surveillance are mostly based on expert opinion rather than evidence.

SUMMARY

Peutz-Jeghers syndrome is an emerging disease that significantly affects the quality of life enjoyed by patients. Despite of all the progress in improved early diagnostics, options for advanced endoscopic therapy and elaborate surveillance, acute and chronic complications decrease the life expectancy of patients suffering from Peutz-Jeghers syndrome.