Video capsule enteroscopy in the diagnosis of celiac disease: a multicenter study

Gastro 2013 APDW/WCOG Shanghai working party report: chronic diarrhea: definition, classification, diagnosis

Diarrhea is best defined as passage of loose stools often with more frequent bowel movements. For clinical purposes, the Bristol Stool Form Scale works well to distinguish stool form and to identify loose stools. Laboratory testing of stool consistency has lagged behind. Acute diarrhea is likely to be due to infection and to be self-limited. As diarrhea becomes chronic, it is less likely to be due to infection; duration of 1 month seems to work well as a cut-off for chronic diarrhea, but detailed scientific knowledge is missing about the utility of this definition. In addition to duration of diarrhea, classifications by presenting scenario, by pathophysiology, and by stool characteristics (e.g. watery, fatty, or inflammatory) may help the canny clinician refine the differential diagnosis of chronic diarrhea. In this regard, a careful history remains the essential part of the evaluation of a patient with diarrhea. Imaging the intestine with endoscopy and radiographic techniques is useful, and biopsy of the small intestine and colon for histological assessment provides key diagnostic information. Endomicroscopy and molecular pathology are only now being explored for the diagnosis of chronic diarrhea. Interest in the microbiome of the gut is increasing; aside from a handful of well-described infections because of pathogens, little is known about alterations in the microbiome in chronic diarrhea. Serological tests have well-defined roles in the diagnosis of celiac disease but have less clearly defined application in autoimmune enteropathies and inflammatory bowel disease. Measurement of peptide hormones is of value in the diagnosis and management of endocrine tumors causing diarrhea, but these are so rare that these tests are of little value in screening because there will be many more false-positives than true-positive results. Chemical analysis of stools is of use in classifying chronic diarrhea and may limit the differential diagnosis that must be considered, but interpretation of the results is still evolving. Breath tests for assessment of carbohydrate malabsorption, small bowel bacterial overgrowth, and intestinal transit are fraught with technical limitations that decrease sensitivity and specificity. Likewise, tests of bile acid malabsorption have had limited utility beyond empirical trials of bile acid sequestrants.

Endoscopic tools for the diagnosis and evaluation of celiac disease

Celiac disease (CD) is an autoimmune disease of the small bowel induced by ingestion of wheat, rye and barley. Current guidelines indicate histological analysis on at least four duodenal biopsies as the only way to diagnose CD. These indications are based on the conception of the inability of standard endoscopy to make diagnosis of CD and/or to drive biopsy sampling. Over the last years, technology development of endoscopic devices has greatly ameliorated the accuracy of macroscopic evaluation of duodenal villous pattern, increasing the diagnostic power of endoscopy of CD. The aim of this paper is to review the new endoscopic tools and procedures proved to be useful in the diagnosis of CD, such as chromoendoscopy, Fujinon Intelligent Chromo Endoscopy, Narrow Band Imaging, Optical Coherence Tomography, Water-Immersion Technique, confocal laser endomicroscopy, high-resolution magnification endoscopy, capsule endoscopy and I-Scan technology.

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.

Comparison of double balloon enteroscopy in adults and children

AIM

To compare results of double balloon enteroscopy (DBE) procedures in pediatric and adult patients.

METHODS

The medical files of patients who underwent DBE at Gazi University School of Medicine, Ankara, Turkey between 2009 and 2011 were examined retrospectively. Adult and pediatric patients were compared according to DBE indications, procedure duration, final diagnosis, and complications. DBE procedures were performed in an operating room under general anesthesia by two endoscopists. An oral or anal approach was preferred according to estimated lesion sites. Overnight fasting of at least 6 h prior to the start of the procedure was adequate for preprocedural preparation of oral DBE procedures. Bowel cleansing was performed by oral administration of sennosides A and B solution, 2 mL/kg, and anal saline laxative enema. The patients were followed up for 2 h after the procedure in terms of possible complications.

RESULTS

DBE was performed in 35 patients (5 pediatric and 30 adult). DBE procedures were performed for abdominal pain, chronic diarrhea, bleeding, chronic vomiting, anemia, and postoperative evaluation of anastomosis. Final diagnosis was diffuse gastric angiodysplasia (n = 1); diffuse jejunal angiodysplasia (n = 1); ulceration in the bulbus (n = 1); celiac disease (n = 1); low differentiated metastatic carcinoma (n = 1); Peutz-Jeghers syndrome (n = 1); adenomatous polyp (n = 1) and stricture formation in anastomosis line (n = 1). During postprocedural follow-up, abdominal pain and elevated amylase levels were noted in three patients and one patient developed abdominal perforation.

CONCLUSION

With the help of technological improvements, we may use enteroscopy as a safe modality more frequently in younger and smaller children.

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.

Video capsule endoscopy in patients with nonresponsive celiac disease

GOALS AND BACKGROUND

Discriminating between patients with nonresponsive but otherwise uncomplicated celiac disease (CD) and patients with refractory celiac disease (RCD) and/or lymphoma is difficult, especially as many abnormalities encountered in complicated CD are not within reach of conventional gastroduodenoscopy. We aimed to describe video capsule endoscopy (VCE) findings in patients with CD and persisting or relapsing symptoms despite a gluten-free diet and to identify VCE findings associated with poor prognosis.

METHODS

We retrospectively analyzed 48 VCE studies performed in adult patients with CD because of persisting or relapsing symptoms despite adherence to a gluten-free diet. Patients with either uncomplicated CD or RCD type I were considered to have a good prognosis, whereas patients with either RCD type II or enteropathy-associated T-cell lymphoma were considered to have a poor prognosis. Multivariate analysis was performed to identify VCE findings independently associated with either good or poor prognosis.

RESULTS

Proximal focal erythema (odds ratio, 6.7; 95% confidence interval, 1.2-38.7; P=0.033) and absence of progression of the capsule to the distal intestine (odds ratio, 16.5; 95% confidence interval, 1.2-224.9; P=0.035) were independently associated with poor prognosis. Of the 28 patients with none of these 2 features, none died during follow-up, compared with 2 (13.3%) of the 15 patients with one of both features, and 4 (80.0%) of the 5 patients with both the features.

CONCLUSIONS

VCE is a minimally invasive endoscopic modality that could be of use in identifying patients with nonresponsive CD who are at risk of poor prognosis.

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.

An unusual method of diagnosing a common disease

A 34-year-old woman presented with non-bloody diarrhoea of 14 days duration and vomiting. Physical examination was unremarkable. She had hypokalaemia and metabolic acidosis. Stool studies were negative for Clostridium difficile toxin, faecal leucocytes and parasites. Colon appeared normal on colonoscopy. Pronounced scalloping of ileal folds was noted on ileoscopy. Ileal biopsies revealed villous blunting, crypt hyperplasia, marked intraepithelial lymphocytosis and lymphocytic infiltration of the lamina propria, consistent with lymphocytic ileitis in coeliac disease. Serology revealed elevated antitissue transglutaminase IgA antibodies (>100 U/ml). Institution of a strict gluten free diet resulted in complete resolution of symptoms. Although rare, coeliac disease can present as an acute diarrhoeal illness and should be considered after infectious aetiologies are excluded.

Transformation of videocapsule images to detect small bowel mucosal differences in celiac versus control patients

BACKGROUND

Videocapsule endoscopy can be useful to detect small intestinal pathology in celiac disease patients. However, presence of extraneous features including air bubbles and opaque fluids can complicate the analysis. A technique for quantitative analysis of videocapsule images is presented that is robust to presence of extraneous features.

METHOD

Videocapsule clips were acquired from five small intestinal locations in 12 celiacs with villous atrophy and 11 control patients. Clips were 200 frames in length, their resolution was 576 × 576 pixels and 256 grayscale levels, with 2/s frame rate. The dominant period (DP), defined as the tallest peak in the ensemble average power spectrum, was computed over each clip without removal of extraneous features. Ensemble average basis images were constructed, and measurements were made of their frame-to-frame variation in brightness and texture.

RESULTS

From pooled basis images, celiac images had greater texture than controls and exhibited more brightness variation (p<0.05 in mean and p<0.01 in standard deviation). In celiacs, correlation existed between greater textural alterations versus longer DP (r²=0.47), and between greater brightness variation and longer DP (r²=0.33). There was no significant correlation between quantitative features and DP in controls (r²<0.25).

CONCLUSIONS

Using this new method, celiac videoclips were quantitatively distinguishable from control videoclips without manual or computer-assisted detection, masking, and removal of extraneous image features. Furthermore, in celiac but not control basis images, larger textural and brightness alterations were correlated to longer DP. Greater textural and brightness alterations, and thus longer periodicities, are likely related to presence of villous atrophy.

Video capsule endoscopy in celiac disease

Video capsule endoscopy (VCE) provides a safe, non-invasive way to visualize the small intestine and is helpful in celiac disease patients in select situations. VCE can be performed in patients who are unable or unwilling to undergo conventional endoscopy, those with positive celiac serology with normal duodenal biopsies, and also in those who develop alarm symptoms. VCE has limitations including subjective interpretation. Techniques are being developed to standardize assessment of VCE images in patients with known or suspected celiac disease. Pilot studies using computer-based quantification methods have shown promise in examining the 3-dimensional mucosal structure and motility.

Is enteroscopy necessary for diagnosis of celiac disease?

Celiac disease (CD) is an autoimmune inflammatory disease of the small intestine as a result of reaction to wheat protein, gluten. Exclusion of dietary gluten is the mainstay of the treatment that necessitates a precise diagnosis of the disease. Serological screening may aid in identifying patients with suspected CD, which should be confirmed by intestinal biopsy. It has been shown that duodenal biopsies are good for detection of the disease in most patients. However, there is a group of patients with positive serology and inconclusive pathology. As a result of the widespread use of serology, many patients with equivocal findings grow quickly. Unfortunately current endoscopic methods can only diagnose villous atrophy, which can be present in the later grades of disease (i.e., Marsh III). To diagnose CD correctly, going deeper in the intestine may be necessary. Enteroscopy can reveal changes in CD in the intestinal mucosa in 10%-17% of cases that have negative histology at initial workup. Invasiveness of the method limits its use. Capsule endoscopy may be a good substitute for enteroscopy. However, both techniques should be reserved for patients with suspected diagnosis of complications. This paper reviews the current literature in terms of the value of enteroscopy for diagnosis of CD.

Serology in adults with celiac disease: limited accuracy in patients with mild histological lesions

Celiac disease (CD) is a gluten-triggered enteropathy, presenting with insidious clinical patterns. It can occasionally be diagnosed in asymptomatic subjects. Our aim was to define the relationship among symptoms at diagnosis, serological markers [tissue transglutaminase antibodies (tTGA), anti-endomysium antibodies (EMA) anti-actin antibodies (AAA)] and degree of mucosal damage. A total of 68 consecutive adult patients with CD were enrolled. Intestinal biopsies were scored according to the Marsh classification modified by Oberhuber: I-II minimal lesions or absent villous atrophy; IIIA partial villous atrophy; IIIB-C total villous atrophy (TVA). HLA-typing was done for all patients. No association between clinical presentation and severity of mucosal damage was found. Presence of EMA or tTGA was significantly associated with more severe mucosal damage (P < 0.001). Of 12 patients, 11 with AAA were also positive for TVA. The severity of mucosal damage is the main factor governing the detectability of serological markers of CD. The sensitivity of serological testing is questionable in patients with minimal lesions.

Diagnosing celiac disease by video capsule endoscopy (VCE) when esophagogastroduodenoscopy (EGD) and biopsy is unable to provide a diagnosis: a case series

Background

Video capsule endoscopy (VCE) is mainly used to evaluate patients with celiac disease in whom their course after diagnosis has been unfavorable and the diagnosis of adenocarcinoma, lymphoma or refractory celiac disease is entertained, but it has been suggested that VCE could replace esophagogastroduodenoscopy (EGD) and biopsy under certain circumstances.

Methods

We report a single center case series of 8 patients with suspected celiac disease who were diagnosed by VCE.

Results

EGD and biopsy had been performed in 4 patients resulting in a negative biopsy, declined by 2, and contraindicated in 2 due to hemophilia and von Willebrand disease. In all patients, mucosal changes of scalloping, mucosal mosaicism and reduced folds were seen in either the duodenum or jejunum on VCE. Follow-up in 7 patients demonstrated improvement in either their serological abnormalities or their presenting clinical features on a gluten-free diet.

Conclusions

Our case series demonstrates that VCE and the visualization of the characteristic mucosal changes of villous atrophy may replace biopsy as the mode of diagnosis when EGD is either declined or contraindicated, or when duodenal biopsies are negative and there remains a high index of suspicion. Further study is needed to clarify the role and cost of diagnosing celiac disease with VCE.

Recent advances in small bowel diseases: Part II

As is the case in all areas of gastroenterology and hepatology, in 2009 and 2010 there were many advances in our knowledge and understanding of small intestinal diseases. Over 1000 publications were reviewed, and the important advances in basic science as well as clinical applications were considered. In Part II we review six topics: absorption, short bowel syndrome, smooth muscle function and intestinal motility, tumors, diagnostic imaging, and cystic fibrosis.

The immunopathogenesis of celiac disease reveals possible therapies beyond the gluten-free diet

Celiac disease is a T cell-mediated autoimmune inflammatory disease of the small intestine that is activated by gluten. The diagnosis of celiac disease is challenging as patients display a wide range of symptoms and some are asymptomatic. A lifelong gluten-free diet is the only currently approved treatment of celiac disease. Although the diet is safe and effective, the compliance rates and patient acceptance vary. Furthermore, many patients treated with a gluten-free diet continue to be mildly to severely symptomatic with persistent histological abnormalities, and a small number of patients develop refractory celiac disease. New therapeutic adjuncts and potential alternatives to the gluten-free diet could improve the treatment options for these patients. Advances in understanding the immunopathogenesis of celiac disease have suggested several types of therapeutic strategies that may augment or supplant the gluten-free diet. Some of these strategies attempt to decrease the immunogenicity of gluten-containing grains by manipulating the grain itself or by using oral enzymes to break down immunogenic peptides that normally remain intact during digestion. Other strategies focus on preventing the absorption of these peptides, preventing tissue transglutaminase from rendering gluten peptides more immunogenic, or inhibiting their binding to celiac disease-specific antigen-presenting molecules. Strategies that limit T cell migration to the small intestine or that reestablish mucosal homeostasis and tolerance to gluten antigens are also being explored. Additionally, it is vital to develop new therapeutic options for refractory celiac disease patients. This review highlights therapeutic strategies that may ultimately improve the health and well-being of individuals with celiac disease.

The role of video capsule endoscopy in the diagnosis of celiac disease: a meta-analysis

BACKGROUND

Video capsule endoscopy (VCE) is an attractive and patient friendly tool that provides high quality images of the small bowel. The reported yield of VCE in diagnosing celiac disease (CD) has shown variable results.

OBJECTIVE

The aim of this study was to assess the accuracy of VCE by pooling data of existing trials.

DESIGN

Meta-analysis. The fixed-effects or random-effects model was used as appropriate, based on whether homogeneity or heterogeneity, respectively, was indicated by the Cochran Q-test.

PATIENTS

Studies that estimated the accuracy of VCE were identified. The two investigators independently conducted the search and data extraction. A total of 166 individuals were included in this meta-analysis.

METHODS

An extensive literature search was performed and studies that estimated the accuracy of VCE in CD were identified. The two investigators independently conducted the search and data extraction. Data from the eligible studies were collected and pooled; sensitivity, specificity, likelihood ratios, and diagnostic odds ratios were computed. In addition, the results of the individual studies were displayed in a receiver operating characteristic (ROC) space to illustrate the distribution of sensitivities and specificities. A weighted symmetric summary ROC curve was computed and the area under the curve (AUC) was calculated, with perfect tests having an AUC of 1 and poor tests having an AUC close to 0.5.

RESULTS

Out of 461 titles initially generated by the literature searches, six studies met the inclusion criteria and were eligible for meta-analysis. The overall pooled VCE sensitivity was 89% [95% confidence interval (82-94%)] and specificity was 95% [95% confidence interval (89-98%)]. The AUC under the weighted symmetric summary ROC was 0.9584.

CONCLUSION

The results of this meta-analysis mean that VCE, although it is not as accurate as pathology, could be a reasonable alternative method of diagnosing CD. Hopefully, this method will expand the portfolio of diagnostic methods available, especially in patients unwilling to undergo gastroscopy because of its perceived inconvenience and discomfort. However, larger, multicenter, and well-designed trials are needed to further establish the role of VCE in the diagnosis of CD.

Video capsule endoscopy in celiac disease: current clinical practice

OBJECTIVE

A complete examination of the small intestine is possible by video capsule endoscopy (VCE). The aim of this study was to evaluate current indications for performing VCE in celiac disease.

METHODS

In all 84 celiac disease patients on a gluten-free diet who had undergone VCE were enrolled at five centers in Europe. The indications, findings and clinical impact of VCE were recorded by a structured questionnaire. VCE was also carried out in 34 consecutive patients with untreated celiac disease (controls) in another center.

RESULTS

Out of the 84 patients, 34 had overt symptoms and small intestinal histology compatible with refractory celiac disease. VCE was normal in 9 patients, and 7 had only proximal and one distal atrophy, 14 had intestinal ulcer and 2 an intestinal stricture. VCE was used in the adjustment of immunosuppressive treatment in 9 patients. In the remaining 50 patients, a VCE was performed because of less severe symptoms, 31 of which had an earlier histological recovery. The VCE showed proximal small bowel atrophy in 21 and distal atrophy in 3 patients, and 3 ulcers were seen. In this group the patients received mainly advice with a view to achieving better dietary compliance. Of the 34 newly detected celiac patients, 4 were normal, 27 proximal and 3 had distal small intestinal atrophy in the VCE.

CONCLUSIONS

VCE has a definite impact on the management of refractory sprue. In the remaining patients with established celiac disease, the procedure plays a more limited role.

Advances in small bowel imaging

The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Within the past 10 years, advances have led to an explosion of technologies that facilitate examination of the entire small intestine. Wireless video capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computer tomography (CT) and magnetic resonance (MR) enterography have facilitated the diagnosis, monitoring, and management of patients with small intestinal diseases. These technologies are complementary, each with its advantages and limitations. Capsule endoscopy provides a detailed view of the mucosal surface and has excellent patient acceptance, but does not allow therapeutics. Deep enteroscopy allows careful inspection of the mucosa and therapeutics, but is time consuming and invasive. Enterography (CT or MR) allows examination of the small bowel wall and surrounding structures. The initial best test for detecting small intestinal disease depends on clinical presentation and an astute differential diagnosis.

Capsule endoscopy in celiac disease

Capsule endoscopy (CE) has been increasingly used for diagnosing disease of the small bowel. It is an attractive technique for assessing celiac disease (CD) because it is noninvasive and provides a close and magnified view of the mucosa of the entire small bowel. The aim of this paper is to update the current data on the use of CE for diagnosing villous atrophy and complications of CD.

Update on celiac disease - etiology, differential diagnosis, drug targets, and management advances

Celiac disease (CD) is an immune-mediated enteropathy triggered by exposure to wheat gluten and similar proteins found in rye and barley that affects genetically susceptible persons. This immune-mediated enteropathy is characterized by villous atrophy, intraepithelial lymphocytosis, and crypt hyperplasia. Once thought a disease that largely presented with malnourished children, the wide spectrum of disease activity is now better recognized and this has resulted in a shift in the presenting symptoms of most patients with CD. New advances in testing, both serologic and endoscopic, have dramatically increased the detection and diagnosis of CD. While the gluten-free diet is still the only treatment for CD, recent investigations have explored alternative approaches, including the use of altered nonimmunogenic wheat variants, enzymatic degradation of gluten, tissue transglutaminase inhibitors, induction of tolerance, and peptides to restore integrity to intestinal tight junctions.

Recent advances in celiac disease

Celiac disease now affects about one person in a hundred in Europe and North America. In this review, we consider a number of important and exciting recent developments, such as clinical associations, HLA-DQ2 and HLA-DQ8 predispositions, the concept of potential celiac disease, the use of new imaging/endoscopy techniques, and the development of refractory disease. This review will be of use to all internists, pediatricians and gastroenterologists.

Capsule endoscopy: a valuable tool in the follow-up of people with celiac disease on a gluten-free diet

OBJECTIVES:

Traditional celiac disease guidelines recommend follow-up endoscopy and duodenal biopsies at 6–12 months after commencing a gluten-free diet (GFD). However, histology may remain abnormal even 1–2 years later. We evaluated the role of capsule endoscopy in patients with celiac disease after treatment with a GFD.

METHODS:

Twelve adult patients with newly diagnosed celiac disease were prospectively enrolled. All patients had baseline symptom assessment, celiac serology (tissue transglutaminase antibody, tTG), and capsule endoscopy. Twelve months after commencing a GFD, patients underwent repeat symptom assessment, celiac serology, upper gastrointestinal endoscopy, and capsule endoscopy.

RESULTS:

At baseline, capsule endoscopy detected endoscopic markers of villous atrophy in the duodenum and extending to a variable distance along the small intestine. On the basis of small bowel transit time, the mean±s.e.m. percentage of small intestine with villous atrophy was 18.2±3.7%. After 12 months on a GFD, repeat capsule endoscopy demonstrated mucosal healing from a distal to proximal direction, and the percentage of small intestine with villous atrophy was significantly reduced to 3.4±1.2% (P=0.0014) and this correlated with improvement in the symptom score (correlation 0.69, P=0.01). There was a significant improvement in symptom score (5.2±1.0 vs. 1.7±0.4, P=0.0012) and reduction in immunoglobulin A–tTG levels (81.5±10.6 vs. 17.5±8.2, P=0.0005). However, 42% of subjects demonstrated persistent villous abnormality as assessed by duodenal histology.

CONCLUSIONS:

After 12 months on a GFD, patients with celiac disease demonstrate an improvement in symptoms, celiac serology, and the extent of disease as measured by capsule endoscopy. Mucosal healing occurs in a distal to proximal direction. The extent of mucosal healing correlates with improvement in symptoms. Duodenal histology does not reflect the healing that has occurred more distally.

What is the use of biopsy and antibodies in coeliac disease diagnosis?

The advent of highly sensitive and specific serological markers has led to some protagonists proposing that coeliac disease can be diagnosed without the need for a biopsy. However, this is an area of controversy. Lack of consensus about diagnostic degrees of histological change, paucity of symptoms, antibody-negative disease and immunodeficiency can make diagnosis difficult even with a biopsy. Conversely, an argument can be put forward for a 'no biopsy' approach based on the large number of patients with typical symptoms and positive serology who experience a diagnostic delay. In addition, endoscopy is not without discomfort. This article discusses the use of antibodies and duodenal biopsy within this context. Finally, we propose a pragmatic diagnostic algorithm for clinicians to use when investigating patients for coeliac disease.

Recent advances in celiac disease

Celiac disease now affects about one person in a hundred in Europe and North America. In this review, we consider a number of important and exciting recent developments, such as clinical associations, HLA-DQ2 and HLA-DQ8 predispositions, the concept of potential celiac disease, the use of new imaging/endoscopy techniques, and the development of refractory disease. This review will be of use to all internists, pediatricians and gastroenterologists.

Age and video capsule endoscopy in obscure gastrointestinal bleeding: a prospective study on hospitalized patients

BACKGROUND

The influence of aging on video capsule endoscopy (VCE) in obscure gastrointestinal bleeding (OGIB) has never been prospectively assessed.

AIMS

To demonstrate if age is a risk factor for incomplete VCE examination in a setting of ongoing hospitalization for OGIB and if it affects the yield of VCE.

METHODS

Forty-eight consecutive patients referred to our unit for obscure-overt GI bleeding from March 2007 to September 2009 were prospectively evaluated. Patients were divided into two groups according to their age: ≤65 years (group A) and >65 years (group B). The VCE completion rate and clinically significant findings were studied.

RESULTS

The cecum was reached in 73% of patients. There was no difference between the two groups of patients in the VCE completion rate (78% vs. 68%, P=0.4). The overall diagnostic yield was 61%. A significant difference in the diagnostic yield between group A and group B (45% vs. 75%, P=0.04) was shown. Angiodysplasia was diagnosed in 13 out of 24 (54%) patients of group B, whereas mucosal breaks, such as erosions or ulcers, accounted for over a quarter of the group A findings.

CONCLUSIONS

Old age is not a risk factor for incomplete VCE examination and it is associated with increased VCE yield.

The role of capsule endoscopy in suspected celiac disease patients with positive celiac serology

BACKGROUND

Endomysial antibody (EMA) and tissue transglutaminase (tTG) antibody testing is used to screen subjects with suspected celiac disease. However, the traditional gold standard for the diagnosis of celiac disease is histopathology of the small bowel. As villous atrophy may be patchy, duodenal biopsies could potentially miss the abnormalities. Capsule endoscopy can obtain images of the whole small intestine and may be useful in the early diagnosis of celiac disease.

AIMS

To evaluate suspected celiac disease patients who have positive celiac serology and normal duodenal histology and to determine, with capsule endoscopy, whether these patients have any endoscopic markers of celiac disease.

METHODS

Twenty-two subjects with positive celiac serology (EMA or tTG) were prospectively evaluated. Eight of the subjects had normal duodenal histology and 14 had duodenal histology consistent with celiac disease. All subjects underwent capsule endoscopy. Endoscopic markers of villous atrophy such as loss of mucosal folds, scalloping, mosaic pattern, and visible vessels were assessed.

RESULTS

Eight subjects with normal duodenal histology had normal capsule endoscopy findings. In the 14 subjects with duodenal histology that was consistent with celiac disease, 13 had celiac disease changes seen at capsule endoscopy. One subject with normal capsule endoscopy findings showed Marsh IIIc on duodenal histology. Using duodenal histology as the gold standard, capsule endoscopy had a sensitivity of 93%, specificity of 100%, PPV of 100%, and NPV of 89% in recognizing villous atrophy.

CONCLUSIONS

Capsule endoscopy is useful in the detection of villous abnormalities in untreated celiac disease. Patients with positive celiac serology (EMA or tTG) and normal duodenal histology are unlikely to have capsule endoscopy markers of villous atrophy.

The role of endoscopic imaging of the small bowel in clinical practice

Enteroscopy, defined as direct visualization of the small bowel (SB) with the use of a fiberoptic or wireless endoscope, has progressed considerably over the past several years. Technological advancements in the field have facilitated endoscopic evaluation of the SB. This comprehensive clinical review summarizes the latest modalities available to aid gastroenterologists in exploring the SB for evaluation of obscure gastrointestinal bleeding, tumors, inflammatory bowel disease, and celiac disease. Previous physical limitations in equipment that made a complete evaluation of the SB difficult have all but disappeared with the advent of capsule endoscopy, balloon-assisted enteroscopy, and spiral enteroscopy.

Video capsule endoscopy: what is the future?

Video capsule endoscopy (VCE) that was launched 10 years ago has become a first-line procedure for examining the small bowel, especially in the case of obscure gastrointestinal bleeding. Other major indications include Crohn disease (CD), celiac disease, and intestinal polyposis syndrome. In the case of small bowel diseases, the use of VCE must be integrated in a global diagnostic and therapeutic approach. More recently, wireless endoscopy has been adapted for examining the colon, opening up larger perspectives for colorectal cancer screening or colon examination. Technologic modifications of the second-generation colon capsule increase the sensitivity of this method for detecting polyps. Other new developments, including remote magnetic manipulation, power management, drug delivery capsule, microbiopsy capsule, and adaptation of technologies such as chromoendoscopy, are sure to enhance the capabilities of wireless endoscopy in gastrointestinal disorders.

Distinguishing patients with celiac disease by quantitative analysis of videocapsule endoscopy images

BACKGROUND

Although videocapsule endoscopy images are helpful in the evaluation of celiac disease, their interpretation is subjective. Quantitative disease markers could assist in determining the extent of villous atrophy and response to treatment.

METHOD

Capsule endoscopy images were acquired from celiac patients with small bowel pathology (N=11) and from control patients (N=10). Image resolution was 576x576 pixels in dimension, 256 grayscale levels, and had a 2 s(-1) frame rate. Pixel brightness and image texture were measured over 10x10 pixel subimages and then averaged for 56x56 subimages per frame. Measurements were obtained at five locations from proximal to distal small intestine in each patient. At each location, measurements were calculated using 200 consecutive image frames (100s). Mean frame-to-frame pixel brightness, image texture, and periodicity in brightness, an estimate of wall motion or intestinal motility, were computed and used for classification with a nonlinear discriminant function.

RESULTS

From pooled data, celiac images had greater texture than did images from control patients (p<0.001) and exhibited more frame-to-frame brightness variation as well (p=0.032). The dominant period of brightness was longer in celiacs (p=0.001), possibly indicating decreased motility. Using the markers for three-dimensional nonlinear classification of celiacs versus controls, sensitivity was 92.7% and specificity was 93.5%. The relationship between dominant period and small intestinal transit time was approximately linear for both celiacs and controls (r(2)=0.42 and r(2)=0.55, respectively).

CONCLUSIONS

Videocapsule images can be quantified to detect villous atrophy throughout the small intestine, and to distinguish individuals with celiac disease from individuals lacking mucosal atrophy.

The diagnostic value of video capsule endoscopy

BACKGROUND AND AIMS

Video capsule endoscopy (VCE) offers the best means of studying small bowel, but is expensive. We investigated how physicians appraise the value of VCE.

METHODS

A questionnaire was sent to remitting physicians comprising questions on the value of VCE in altogether 189 adults. The follow-up time was at least one year. The patient history was also scrutinized in case records.

RESULTS

The most common indications for VCE were anaemia (n=100) or gastrointestinal bleeding (n=21) (60%), suspicion of Crohn's disease (21%), abdominal pain (9%) and coeliac disease (6%). The diagnostic value of VCE was rated best in patients suffering from anaemia or bleeding, being decisive or beneficial in 33% (OR 2.3, CI=1.1-4.8 compared to all series) and helpful in exclusion in an additional 36%. In Crohn's disease, VCE was helpful in the exclusion of intestinal lesions in 50% of cases; in coeliac disease the corresponding percentage was 42%. When abdominal pain was the only indication for VCE, the examination was beneficial in one patient only.

CONCLUSIONS

The diagnostic value of VCE was evident in patients with anaemia or gastrointestinal bleeding. The procedure was deemed to be helpful in exclusion also in Crohn's disease and in coeliac disease. Abdominal pain was a rare indication, and the diagnostic yield limited.

Classification of videocapsule endoscopy image patterns: comparative analysis between patients with celiac disease and normal individuals

BACKGROUND

Quantitative disease markers were developed to assess videocapsule images acquired from celiac disease patients with villous atrophy, and from control patients.

METHOD

Capsule endoscopy videoclip images (576 x 576 pixels) were acquired at 2/second frame rate (11 celiacs, 10 controls) at regions: 1. bulb, 2. duodenum, 3. jejunum, 4. ileum and 5. distal ileum. Each of 200 images per videoclip (= 100s) were subdivided into 10 x 10 pixel subimages for which mean grayscale brightness level and its standard deviation (texture) were calculated. Pooled subimage values were grouped into low, intermediate, and high texture bands, and mean brightness, texture, and number of subimages in each band (nine features in all) were used for quantifying regions 1-5, and to determine the three best features for threshold and incremental learning classification. Classifiers were developed using 6 celiac and 5 control patients' data as exemplars, and tested on 5 celiacs and 5 controls.

RESULTS

Pooled from all regions, the threshold classifier had 80% sensitivity and 96% specificity and the incremental classifier had 88% sensitivity and 80% specificity for predicting celiac versus control videoclips in the test set. Trends of increasing texture from regions 1 to 5 occurred in the low and high texture bands in celiacs, and the number of subimages in the low texture band diminished (r(2) > 0.5). No trends occurred in controls.

CONCLUSIONS

Celiac videocapsule images have textural properties that vary linearly along the small intestine. Quantitative markers can assist in screening for celiac disease and localize extent and degree of pathology throughout the small intestine.

Classification of videocapsule endoscopy image patterns: comparative analysis between patients with celiac disease and normal individuals

Background

Quantitative disease markers were developed to assess videocapsule images acquired from celiac disease patients with villous atrophy, and from control patients.

Method

Capsule endoscopy videoclip images (576 × 576 pixels) were acquired at 2/second frame rate (11 celiacs, 10 controls) at regions: 1. bulb, 2. duodenum, 3. jejunum, 4. ileum and 5. distal ileum. Each of 200 images per videoclip (= 100s) were subdivided into 10 × 10 pixel subimages for which mean grayscale brightness level and its standard deviation (texture) were calculated. Pooled subimage values were grouped into low, intermediate, and high texture bands, and mean brightness, texture, and number of subimages in each band (nine features in all) were used for quantifying regions 1-5, and to determine the three best features for threshold and incremental learning classification. Classifiers were developed using 6 celiac and 5 control patients' data as exemplars, and tested on 5 celiacs and 5 controls.

Results

Pooled from all regions, the threshold classifier had 80% sensitivity and 96% specificity and the incremental classifier had 88% sensitivity and 80% specificity for predicting celiac versus control videoclips in the test set. Trends of increasing texture from regions 1 to 5 occurred in the low and high texture bands in celiacs, and the number of subimages in the low texture band diminished (r² > 0.5). No trends occurred in controls.

Conclusions

Celiac videocapsule images have textural properties that vary linearly along the small intestine. Quantitative markers can assist in screening for celiac disease and localize extent and degree of pathology throughout the small intestine.

Role of confocal endomicroscopy in the diagnosis of celiac disease

BACKGROUND AND AIMS

Confocal laser endomicroscopy (CLE) is a recent development that enables surface and subsurface imaging of living cells in vivo at 1000 x magnification. The aims of the present study were to define confocal features of celiac disease (CD) and to evaluate the usefulness of the CLE in the diagnosis of CD in children in comparison to histology.

PATIENTS AND METHODS

Nine patients (8 girls) with a median age of 8.35 years (range 2-12.66 years) and a median weight of 28.3 kg (range 11-71 kg) were suspected with CD and 10 matched controls underwent oesophagogastroduodenoscopy using the confocal laser endomicroscope (EC3870CILK; Pentax, Tokyo, Japan). Histologic sections were compared with the confocal images of the same site by 2 experienced paediatric histopathologists and endoscopists, all of whom were blinded to the diagnosis.

RESULTS

The median procedure time was 17 minutes (range 8-25 minutes). Confocal features of CD were defined and a score was developed. A total of 1384 confocal images were collected from 9 patients and 10 controls. Five images from each patient and control were selected and compared with the biopsy specimen of the same site. The sensitivity, specificity, and positive predictive value for the confocal images in comparison to the histology were 100%, 80%, and 81%. The kappa inter-observer agreement between the 2 endoscopists was 0.769 (P = 0.018) and between the 2 histopathologists was 0.571 (P = 0.05).

CONCLUSIONS

Confocal endomicroscopy offers the prospect of diagnosis of CD during ongoing endoscopy. It also enables targeting biopsies to abnormal mucosa and thereby increasing the diagnostic yield, especially when villous atrophy is patchy in the duodenum.

Current methods to diagnose the unresponsive and complicated forms of coeliac disease

Coeliac disease is a common disorder. Due to the protean manifestations of the disease and the often mild but indolent course, the diagnosis is often missed. The method to diagnose this in principle reversible disease after the introduction of a gluten-free diet has attracted the attention of several scientific disciplines to find the simplest and most patient-friendly test. This has resulted in a noticeable impact on the clinical practice next to a general increased awareness of its existence, its pathogenesis, its course and recent evidence of increased mortality. Amendments made in the diagnostic criteria of coeliac disease over the last half century have simplified the diagnosis. However, the aspect most relevant to the specialist in internal medicine is related to its grave consequences when the disease fails to respond to a gluten-free diet. These refractory cases may culminate in severe complications with sombre endings and malignancy. Fortunately, current technology can offer the specialist in internal medicine more facilities to diagnose the cause of the complicated cases in order to attempt to intervene in the course of disease and hopefully save these patients. We review the available tools that now exist and their indications that can be practiced in a modern clinical setting for the diagnosis of the complicated forms of this disease.

10 years of capsule endoscopy: an update

Capsule endoscopy (CE) has evolved in a few short years to become a first-line, noninvasive diagnostic technique for the small bowel. CE is now being utilized worldwide to assess patients for obscure gastrointestinal bleeding, possible Crohn's disease, celiac disease and small bowel tumors. The device is now used in tandem with balloon enteroscopy to direct therapeutic interventions. Alterations and improvements in CE have also led to the evaluation of both the esophagus and colon. It can be anticipated that in the near future pan CE of the entire GI tract will be performed, as well as possible tissue acquisition, drug delivery and therapeutic interventions.

Inter-observer agreement for detection of small bowel Crohn's disease with capsule endoscopy

OBJECTIVE

Compared to other modalities, capsule endoscopy (CE) has a high diagnostic yield for diagnosing small bowel Crohn's disease (CD). The aim of this study was to determine the inter-observer agreement for detection of small bowel CD with predefined diagnostic criteria.

MATERIAL AND METHODS

Thirty patients with suspected or known CD were included in the study. Observers were blind to patient histories, the results of ileo-colonoscopies, and small bowel examinations. More than three ulcerations (aphthous lesions or ulcers) or the presence of stenosis caused by inflammation or fibrosis was diagnostic of small bowel CD. Three observers with experience in gastrointestinal endoscopy and CE participated in the study.

RESULTS

The presence or absence of small bowel CD was determined with complete agreement in 23 patients, nine patients with and 14 without small bowel CD. The inter-observer agreement was substantial for the diagnosis (kappa = 0.68) and moderate for the localization of CD (kappa = 0.44). Aphthous lesions were detected with only fair agreement (kappa = 0.38). The time intervals to passage of the pylorus and ileo-caecal valve were detected with excellent intra-class correlation.

CONCLUSIONS

CE is performed with substantial inter-observer agreement for detection of small bowel CD. In the majority of patients, the presence or absence of small bowel CD is unequivocal. However, in patients with few or minor lesions, the diagnosis is observer dependent.

Capsule endoscopy: 10 years on and in the frontline

Capsule endoscopy is a safe, simple, remote method of visualising the gastrointestinal tract without resorting to conventional endoscopic intubation or radiation exposure. In addition, the ability to visualise the small bowel mucosa directly means that it is considerably more sensitive than existing small bowel imaging modalities in detecting subtle abnormalities. It is a firstline investigative modality for suspected small bowel bleeding and is being increasingly used for detecting evidence of other small bowel diseases. In Crohn's disease, it can confirm evidence of activity without recourse to repeated endoscopic intubation or radiation but does not replace MRI and CT which are better suited to defining stricturing disease and transmural complications. The production of different capsule endoscopes to examine the oesophagus, small bowel and colon now means that almost all of the gut can be examined using this technology.

Fields of applications, diagnostic yields and findings of OMOM capsule endoscopy in 2400 Chinese patients

AIM: To retrospectively analyze the fields of application, diagnostic yields and findings of OMOM capsule endoscopy in Chinese patients.

METHODS: A database including 2400 Chinese patients who received OMOM capsule endoscopy in 27 endoscopy centers in China was retrieved from the Jianshan Science and Technology Ltd. OMOM capsule endoscopy database. The patient’s age, gender, fields of application, the potentially relevant findings, pyloric transit time (PTT), small bowel transit time (SBTT), and complete small-bowel examination rate (CSER) were recorded and analyzed.

RESULTS: Two thousand four hundred patients aged 9-91 years (mean, 49 years), of whom 1510 were males (62.9%), underwent 2400 OMOM capsule endoscopy procedures. One thousand two hundred and thirty two (51.3%) were referred with obscure gastrointestinal bleeding (OGIB), 642 (26.8%) with abdominal pain, and 223 (9.3%) with chronic diarrhea. The overall diagnostic yield was 47.7% (1144/2400). The diagnostic yield of OMOM capsule endoscopy in OGIB subgroup was much higher than in the non-OGIB subgroup (62.4% vs 32.1%, P < 0.001). The most common findings of the small bowel in Chinese patients with OGIB were arteriovenous malformation (28.1%) and tumors (18.9%). There was no significant difference in the diagnostic yield between the male and female patients with OGIB. However, the diagnostic yield in patients aged more than 60 was higher than in patients aged less than 60 (69.8% vs 58.9%, P < 0.001). The median PTT was 41 min (range: 1-544 min) and the mean SBTT was 247.2 ± 88.9 min. The overall CSER was 86.8%.

CONCLUSION: The OMOM capsule endoscopy is a valuable tool for small bowel evaluation with good overall diagnostic yield and CSER.

Diagnostic characteristics of given video capsule endoscopy in diagnosis of celiac disease: a meta-analysis

BACKGROUND AND AIMS

In the view of small sample sizes of the studies published so far, the value of video capsule endoscopy (VCE) in diagnosing celiac disease (CD) is yet to be determined. The aim of this work was to systemically determine the overall diagnostic characteristics of VCE in diagnosing noncomplicated CD, compared to the gold standard, using meta-analysis.

PATIENTS AND METHODS

An extensive literature search was performed looking for prospective, controlled trials, with investigators blinded to results of the pathology of small-bowel biopsies. Two independent authors performed data extraction and assessment of the methodologic quality of each trial. Diagnostic characteristics of each trial were collected, and pooled sensitivity, specificity, likelihood ratios, and diagnostic odds ratios were computed. Description of complications and costs was included, if reported.

RESULTS

A total of three studies met the inclusion criteria (n = 107; 63 with CD and 44 without). The overall pooled VCE sensitivity was 83% (95% confidence interval [CI] = 71-90%) and specificity was 98% (95% CI = 88-99.6%). No major complications were reported. The costs were mentioned only in one study.

CONCLUSIONS

The overall diagnostic characteristics of VCE, when used to diagnose celiac disease, though good with an experienced eye, could not justify the routine use of VCE as an alternative to the pathology of small-bowel biopsies. More studies are needed with proper cost-benefit analysis.

The Antro-pyloric Capsular Movement by Capsule Endoscopy

Background/Aims

Capsule endoscopy (CE) is used for various purposes. The aims of this study were to classify the types of antro-pyloric capsular movement in CE and to investigate the relationship between the types of capsular movement and clinical factors, including gastric emptying time (GET).

Methods

Out of 103 patients who received CE between January 2004 and July 2006, 82 patients (33 female, mean age of 50.6 years) were retrospectively analyzed for capsular movement; 21 patients were excluded because of the history of medications and previous surgeries. CE images were interpreted by a single investigator in relation to the GET and types of antro-pyloric capsular movement.

Results

Antro-pyloric capsular movement was classified into four patterns: type 1, large longitudinal to-and-fro movements in the antrum followed by passage through the pylorus without resistance; type 2, after large longitudinal to-and-fro movements, passage through the pylorus with resistance (> 1 minute); type 3, mixed pattern of type 1 and 4; type 4, weak movement. Median GET by CE were 14.1 minutes (range, 1.2-50.1), 21.7 minutes (6.2-154.9), 57.3 minutes (14.9-249.8), and 58.8 minutes (21.0-249.5) for type 1, 2, 3, and 4, respectively. GET in type 1 and 2 were significantly shorter than that in type 3 and 4 (p < 0.05). Ten diabetic patients presented with type 2 (n = 5), 3 (n = 3), and 4 (n = 2) patterns, but not with type 1.

Conclusions

Our results suggest the analysis of capsule movement using CE to be a possible method of evaluating the antro-pyloric movement.

Video capsule endoscopy of the small bowel

PURPOSE OF REVIEW

It is now over 8 years since small bowel capsule endoscopy (SBCE) was first introduced to the gastrointestinal community. The original capsule (Given Imaging, YoKneam, Israel) - a disposable 26 x 11 mm video capsule containing its own optical dome, light source, batteries, transmitter and antenna - is swallowed with water after a 12 h fast. The capsule is propelled via peristalsis through the gastrointestinal tract and is excreted naturally. We will review all recent work concerning SBCE.

RECENT FINDINGS

At present there are three other SBCEs in the market. SBCE has become a first-line tool to detect abnormalities in the small bowel, as all other imaging technologies are rather ineffective, or very tedious.Indications for SBCE include obscure gastrointestinal bleeding, suspected small bowel tumor, suspected Crohn's disease, surveillance of inherited polyposis syndromes, drug-induced small bowel injury or any abnormal small bowel imaging and new ones are emerging like small bowel motility. Since most of the articles in the literature relate to the PillCam small bowel capsule the data presented will refer mainly to this capsule endoscopy.

SUMMARY

SBCE has shed new light into our knowledge of the small bowel, paving the way for new modalities to come.