Current status of small bowel radiography

Diagnostic Yields and Clinical Impacts of Capsule Endoscopy

Observing the entire small bowel is difficult due to the presence of complex loops and a long length. Capsule endoscopy (CE) provides a noninvasive and patient-friendly method for visualizing the small bowel and colon. Small bowel capsule endoscopy (SBCE) has a critical role in the diagnosis of small bowel disorders through the direct observation of the entire small bowel mucosa and is becoming the primary diagnostic tool for small bowel diseases. Recently, colon capsule endoscopy (CCE) was also considered safe and feasible for obtaining sufficient colonic images in patients with incomplete colonoscopy, in the absence of bowel obstruction. This review article assesses the current status of CE in terms of the diagnostic yield and the clinical impact of SBCE in patients with obscure gastrointestinal bleeding, who have known or suspected Crohn's disease, small bowel tumor and inherited polyposis syndrome, celiac disease, and those who have undergone CCE.

Accuracy of Plain Abdominal Radiography in the Differentiation between Small Bowel Obstruction and Small Bowel Ileus in Acute Abdomen Presenting to Emergency Department

Introduction

Our purpose was to evaluate whether plain abdominal radiography (PAR) could accurately differentiate between small bowel obstruction (SBO) and small bowel ileus (SBI) in an emergency setting. We also evaluated the value of known classic signs on the PAR for differentiating between SBO and SBI.

Methods

This retrospective study included 216 emergency room patients who had small bowel distension (maximal small bowel diameter ≥2.5 cm) on the PAR and who underwent successive abdominal computed tomography. One radiologist and one emergency physician retrospectively reviewed PAR in consensus, unaware of the patients' clinical data; they divided the patients into an SBO group and an SBI group according to the radiographic findings. Presence or numeric values of 10 radiographic signs were also recorded. Final diagnoses of SBO and SBI were established by a combined analysis of medical charts, surgical records, radiographic findings on abdominal computed tomography, and small bowel studies. The differential diagnoses based on PAR and the final diagnoses were compared, and the sensitivity and specificity of PAR were calculated. We also evaluated the differences among 10 radiographic signs between the final SBO and SBI groups.

Results

Sensitivity and specificity of PAR for SBO were 82.0% and 92.4%, respectively. Among the 10 radiographic signs, all except maximal colon diameter were statistically significant predictors on the final diagnosis.

Conclusions

PAR is an accurate and effective initial imaging modality for differentiating between SBO and SBI in an emergency setting, and most of the classic radiographic signs have a diagnostic value.

Improved detection of inflammatory bowel disease by additional automated motility analysis in magnetic resonance imaging

OBJECTIVES

The objective of this study was to evaluate whether the use of automatically generated maps of bowel motility (motility mapping) in magnetic resonance imaging (MRI) leads to an increased detection rate of inflammatory bowel disease.

MATERIALS AND METHODS

Fifty consecutive patients with suspected or known inflammatory bowel disease who underwent bowel MRI using a 1.5-T scanner were analyzed retrospectively. In addition to standard small bowel magnetic resonance protocol, a dynamic coronal T2-weighted sequence (dynamic MRI) was acquired. Dynamic sequences were used to automatically generate a parametric map depicting bowel motility. Two readings of the MRI were performed: first, evaluation of static MRI alone and second, evaluation of static MRI combined with dynamic MRI (motility mapping). Static MRI was analyzed on parameters defining inflammation (morphology, enhancement). Dynamic MRI (motility mapping) was evaluated on the basis of a color-coded scheme displaying hypomotility and hypermotility.

RESULTS

Using motility maps, additional inflammatory lesions were found in 13 (26%) of the 50 patients, resulting in a significantly higher detection rate using static MRI together with motility mapping compared with static MRI alone (P = 0.0002). Overall, 66 inflammatory lesions of the bowel were detected in a total of 38 patients (static MRI + motility mapping) versus 51 lesions in 34 patients (sole evaluation of static MRI).

CONCLUSIONS

Motility assessment of the bowel provides additional information and improves the detection of inflammatory lesions in MRI.

Imaging in the evaluation of the young patient with inflammatory bowel disease: what the gastroenterologist needs to know

Imaging plays a pivotal role in the diagnosis and management of children and young adults with inflammatory bowel disease. The clinician is presented with numerous imaging options, and it can be challenging to decide which test is the best option. In this article we review the present imaging techniques available in the evaluation of inflammatory bowel disease, with emphasis on the advantages, disadvantages, and radiation burden of each test. Finally, we highlight a few common clinical scenarios and propose an imaging algorithm to approach these diagnostic challenges.

Diagnostic imaging in Crohn's disease: what is the new gold standard?

Historically Barium and isotope studies been used for imaging of inflammatory bowel disease (IBD) but carry risk of radiation exposure. Use of Barium is declining resulting in fewer radiologists that have the necessary expertise. Isotopes studies lack anatomical definition but 18F - fludeoxyglucose (FDG) positron emission tomography (PET) shows promise in accurate assessment of disease compared to endoscopy. Computerised tomography (CT) is particularly useful in assessment of complications of Crohn's disease (CD) but radiation exposure is high. CT enterography (CTE) has improved visualisation of small bowel mucosal disease and allows assessment of disease activity. Ultrasound is increasingly used for preliminary assessment of patients with potential IBD. Although widely available and economically attractive, the expertise required is not widespread. Finally magnetic resonance imaging (MRI) is proving to be the most accurate tool for assessment of disease extent and distribution. MRI of the pelvis has superseded other techniques in assessment of peri-anal fistulation.

Acute obstruction

Acute obstruction of the gastrointestinal or biliary tract represents a common problem for acute care surgeons. It is with appropriate clinical evaluation, planning, and physical examination follow-up that acute care surgeons are able to appropriately diagnose, manage, and resolve this difficult group of surgical problems and minimize the morbidity associated with each.

Is a repeat double balloon endoscopy in the same direction useful in patients with recurrent obscure gastrointestinal bleeding?

GOALS

To evaluate the usefulness of repeat double balloon endoscopy (DBE) in obscure gastrointestinal bleeding (OGIB).

BACKGROUND

OGIB recurs in 11% to 42% of patients after DBE. Little is known about the outcome of repeat DBE in recurrent OGIB after DBE.

STUDY

We reviewed clinical course of patients who underwent repeat DBE for recurrent OGIB in the same direction as in previous DBE. Diagnostic yield and therapeutic intervention of repeat DBE were analyzed.

RESULTS

Thirty-five repeat DBEs were performed in 32 patients (M:F=15:17; age range, 36 to 85 y). The first DBE identified a probable bleeding source in 21 (65.6%) patients. Angiodysplasia was the most common and was found in 16 patients. The second DBEs were performed after a median of 30 weeks (range, 1 to 204 wk). Oral approach only was performed in 28 patients and anal approach only in 4. Probable bleeding sources were detected in 17 (53.1%) patients. Sixteen (94.1%) cases were angiodysplasia, of which 14 patients had angiodysplasia also at the first DBE. All detected bleeding sources were managed with endoscopic interventions such as argon plasma coagulation. Seventeen of 21 patients with positive first DBE showed bleeding source at the repeat DBE, whereas none of the 11 patients with negative first DBE did (81.0% vs. 0%; P<0.001). Three patients underwent the third DBE. Angiodysplasias were detected in 2 patients (66.7%).

CONCLUSIONS

Repeat DBE in the same direction may detect bleeding sources in 53% of recurrent OGIB patients. The probability of bleeding source detection in repeat DBE is higher in patients with a prior positive DBE.

Imaging of pediatric patients with inflammatory bowel disease

OBJECTIVE

The goal of this review is to examine the current imaging literature and develop basic imaging guidelines for evaluation of children with inflammatory bowel disease (IBD). The three following typical clinical scenarios in the imaging evaluation of IBD are considered: patient with an initial diagnosis of suspected IBD, the goals being to determine disease extent and severity and to differentiate Crohn disease from ulcerative colitis; patient with known IBD presenting with new acute symptoms (fever, peritonitis, leukocytosis) requiring urgent evaluation; and patient with known IBD presenting with nonacute symptomatic recurrence (abdominal pain, diarrhea), the goals being to assess the efficacy of the current treatment and to evaluate the possible need for additional medical or surgical intervention.

CONCLUSION

Imaging of pediatric patients with IBD must balance considerations of diagnostic accuracy against concerns about patient exposure to ionizing radiation and tolerance of the imaging technique. The imaging modality chosen depends on the clinical presentation and expected pathologic finding.

Small bowel endoscopy and Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant inherited disease. It is clinically characterized by the development of gastrointestinal hamartomas, mainly located in the small bowel. These hamartomas are prone to complications such as intussusceptions, abdominal complaints and anaemia. Furthermore, patients are at increased risk for developing small bowel cancer. Therefore, regular surveillance of the small bowel is indicated. However, the optimal strategy for surveillance has not been determined yet. This review gives an overview of the different techniques that have been described to examine the small bowel of PJS patients. First, a number of radiologic and endoscopic imaging modalities with diagnostic value are discussed. Secondly, recently developed advanced endoscopy techniques are described that can serve both as a diagnostic and therapeutic tool in the surveillance of the small bowel. Finally, a recommendation is given how to apply these individual techniques for small bowel surveillance in a step-up approach.

Accuracy of imaging for predicting operative approach in Crohn's disease

Background

The aim of this study was to assess the accuracy of preoperative imaging in detecting the extent of disease and predicting the operative approach in patients with Crohn's disease.

Methods

Patients with Crohn's disease who were scheduled to undergo operation were evaluated before operation using computed tomography enteroclysis (CTE) and magnetic resonance enterography (MRE). Preoperative imaging findings were correlated with intraoperative and pathological findings to estimate the capabilities of preoperative imaging in detecting lesions due to Crohn's disease. The operative approach determined before surgery was compared with the procedure actually performed, which was based on intraoperative findings.

Results

Fifty-two patients with Crohn's disease were studied; 26 were evaluated before surgery with CTE and 26 with MRE. Eighty-nine lesions due to Crohn's disease were confirmed surgically (60 small bowel stenoses, 21 fistulas and 8 abscesses). CTE confirmed the presence of 38 of 41 lesions (sensitivity 93 per cent) and MRE 48 of 48 lesions (sensitivity 100 per cent); a correct estimation of the disease with an exact prediction of the operative approach was obtained in 49 (94 per cent) of 52 patients. Discrepant findings between preoperative imaging and operative findings were observed in three patients (6 per cent), who had CTE.

Conclusion

Preoperative imaging using CTE or MRE is highly accurate for assessing Crohn's disease lesions before operation, allowing correct prediction of the operative approach.

Small bowel imaging in Crohn's disease

Imaging of Crohn's disease of the small bowel is gradually moving away from barium fluoroscopy and towards cross-sectional modalities. This review explores the strengths and limitations of various techniques, and focuses on several current questions in small bowel imaging, such as the comparison between oral ingestion or nasojejunal intubation and enteroclysis for introduction of contrast, the use of computerised tomography (CT) versus magnetic resonance (MR) and the likely changes over the next decade.

Radiological imaging of the small bowel

Recently introduced endoscopy-based imaging methods such as double-balloon endoscopy or wireless capsule endoscopy can visualize the complete small bowel. These approaches are quite invasive diagnostic methods. Therefore, radiological small bowel imaging is also still considered as the primary imaging approach to diagnose pathological changes of the small bowel. In this review article the most important small bowel imaging modalities such as conventional fluoroscopy, computed tomography, magnetic resonance imaging and ultrasound are discussed. Additionally the most important diseases, which can affect the small bowel, are evaluated and the optimal imaging modalities are pointed out, respectively.

Recent advances in intestinal imaging

In recent years, advances in scanner technology and competition from other specialties have produced rapid changes in the way the intestines are imaged. MRI and CT scan along with the traditional enteroclysis examination have emerged at the forefront of intestinal imaging. Functional modalities such as diffusion and perfusion imaging are also changing the way tumors and inflammatory bowel diseases are evaluated. CT colonography is now a valid alterative to optical colonoscopy. Contrast-enhanced USG is being used for the assessment of inflammation and post-treatment changes. In this review, recent advances in intestinal imaging are described.

Guide to magnetic resonance in Crohn's disease: from common findings to the more rare complicances

Considering that multiple imaging examinations are often necessary for monitoring Crohn's disease (CD) activity and severity in order to guide and monitor appropriate treatment, the ideal imaging test would be reproducible, well tolerated by patients, and free of ionizing radiation. For these reasons recent studies have highlighted the role of a magnetic resonance imaging (MRI) technique optimized for small bowel imaging in the evaluation of small bowel disorders. In this regard there are two main methodological approaches represented by MR enterography, following administration of an oral contrast medium, and MR enteroclysis, following administration of contrast medium through a nasojejuneal tube. MRI may be used to demonstrate the pathologic findings and complications of CD. In particular, MR has excellent sensitivity and specificity, ranging from 88%-98% and 78%-100%, respectively, for the detection of active inflammation, wall thickening, ulcerations, increased wall enhancement, increased vascularity, perienteric inflammation, and reactive adenopathy. MR also allows more accurate identification of associated complications including penetrating and fibrostenotic disease as well as the more rare extraintestinal manifestations that are usually associated with severe and longstanding intestinal inflammation, the latter often guiding the therapeutic approach. In the progression of CD some rare complications can occur that, to our knowledge, were only briefly or never mentioned in the radiological literature regarding MR enterography or enteroclysis and in which the application of these techniques play a key role.

Diffuse infantile hemangiomatosis of the ileum presenting with multiple perforations: a case report and review of the literature

Hemangiomas of the small intestine are rare, accounting for only 0.05% of all intestinal neoplasms (Jarvi et al. J Pediatr Gastroenterol Nutr. 2008;46:593-597). The jejunum is the most common site of involvement in the small intestine (Levy et al. Am J Roentgenol. 2001;177:1073-1081). Small bowel hemangiomas are most commonly manifested by gastrointestinal bleeding, abdominal pain, obstruction, or intussusception. There are very few reported cases in the literature of hemangiomatosis presenting with perforation, and only 1 previously reported case of perforation in the ileum. We present a rare case of a 5-week-old female with diffuse hemangiomatosis of the ileum presenting with multiple ileal perforations and peritonitis.

Capsule endoscopy in small bowel tumors: a multicenter Korean study

BACKGROUND AND AIM

Capsule endoscopy (CE) has proven to be highly effective at detecting small bowel lesions in a variety of clinical conditions, but studies concerning the practical impact of CE on small bowel tumors are still scarce, especially in the Asian population. The aim of this study was to evaluate the diagnostic and therapeutic impact of CE in the field of small bowel tumors.

METHODS

CE records consecutively pooled from the beginning of use of CE in Korea, October 2001 until April 2008, in 14 centers throughout Korea were reviewed. Clinical information and CE video images of small bowel tumors were analyzed.

RESULTS

A total of 1332 cases undergoing CE were reviewed with all clinical indications. Small bowel tumors were diagnosed with CE in 57 (4.3%) of 1332 patients. The tumors were malignant in 33 cases, and included three adenocarcinomas, eight lymphomas, 20 gastrointestinal stromal tumors, and two metastatic cancers. The most frequent indications for CE in malignant tumors were obscure gastrointestinal bleeding, followed by abdominal pain and weight loss. Thirty of 57 tumors were identified exclusively by CE (diagnostic impact = 30/57), and they were smaller in size (mean, range: 14.3 mm, 2-35 mm) compared to the other tumors detected in radiological studies (48.7 mm, 10-110 mm). Seven patients underwent surgical resection (therapeutic impact = 7/57).

CONCLUSION

CE effectively identifies small bowel tumors that are undetectable by conventional radiological studies (diagnostic impact = 52.6%) and can critically change the therapeutic course (therapeutic impact = 12.3%).

Magnetic resonance enterography in Crohn’s disease: Standard and advanced techniques

Crohn’s disease (CD) is a chronic autoimmune disorder that affects mainly young people. The clinical management is based on the Crohn’s Disease Activity Index and especially on biologic parameters with or without additional endoscopic and imaging procedures, such as barium and computed tomography examinations. Recently, magnetic resonance (MR) imaging has been a promising diagnostic radiologic technique with lack of ionizing radiation, enabling superior tissue contrast resolution due to new pulse-sequence developments. Therefore, MR enterography has the potential to become the modality of choice for imaging the small bowel in CD patients.

Occult and obscure gastrointestinal bleeding: Causes and diagnostic approach in 2009

Gastrointestinal bleeding can be obscure or occult (OGIB), the causes and diagnostic approach will be discussed in this editorial. The evaluation of OGIB consists on a judicious search of the cause of bleeding, which should be guided by the clinical history and physical findings. The standard approach to patients with OGIB is to directly evaluate the gastrointestinal tract by endoscopy, abdominal computed tomography, angiography, radionuclide scanning, capsule endoscopy. The source of OGIB can be identified in 85%-90%, no bleeding sites will be found in about 5%-10% of cases. Even if the bleedings originating from the small bowel are not frequent in clinical practice (7.6% of all digestive haemorrhages, in our casuistry), they are notoriously difficult to diagnose. In spite of progress, however, a number of OGIB still remain problematic to deal with at present in the clinical context due to both the difficulty in exactly identifying the site and nature of the underlying source and the difficulty in applying affective and durable diagnostic approaches so no single technique has emerged as the most efficient way to evaluate OGIB.

Crohn disease of the small bowel: comparison of CT enterography, MR enterography, and small-bowel follow-through as diagnostic techniques

PURPOSE

To prospectively compare the accuracy of computed tomographic (CT) and magnetic resonance (MR) enterography and small-bowel follow-through (SBFT) examination for detection of active small-bowel inflammation and extraenteric complications in patients with Crohn disease (CD).

MATERIALS AND METHODS

The institutional review board approved the study protocol; informed consent was obtained from all participants. Thirty-one consecutive patients who had CD or who were suspected of having CD underwent CT and MR enterography, SBFT, and ileocolonoscopy. Two independent readers reviewed CT and MR enterographic and SBFT images for presence of active terminal ileitis and extraenteric complications. Accuracy values of CT and MR enterography and SBFT for identification of active terminal ileitis were evaluated with the receiver operating characteristic method, with ileocolonoscopic findings as the reference standard. Sensitivity values of CT and MR enterography and SBFT for detection of extraenteric complications were compared by using the McNemar test, with results of imaging studies, surgery, and physical examination as reference standards.

RESULTS

The study population included 30 patients (17 men, 13 women; mean age, 29.0 years) with CD. Differences in areas under the receiver operating characteristic curves for CT enterography (0.900 and 0.894), MR enterography (0.933 and 0.950), and SBFT (0.883 and 0.928) for readers 1 and 2, respectively, in the detection of active terminal ileitis were not significant (P > .017). Sensitivity values for detection of extraenteric complications were significantly higher for CT and MR enterography (100% for both) than they were for SBFT (32% for reader 1 and 37% for reader 2) (P < .001).

CONCLUSION

Because MR enterography has a diagnostic effectiveness comparable to that of CT enterography, this technique has potential to be used as a radiation-free alternative for evaluation of patients with CD.

Barium meal follow through with pneumocolon: Screening test for chronic bowel pain

AIM: To study the sensitivity, specificity and cost effectiveness of barium meal follow through with pneumocolon (BMFTP) used as a screening modality for patients with chronic abdominal pain of luminal origin in developing countries.

METHODS: Fifty patients attending the Gastroenterology Unit, SMS Hospital, whose clinical evaluation revealed chronic abdominal pain of bowel origin were included in the study. After routine testing, BMFT, BMFTP, contrast enhanced computed tomography (CECT) of the abdomen, barium enema and colonoscopy were performed. The sensitivity, specificity and cost effectiveness of these imaging modalities in the detection of small and/or large bowel lesions were compared.

RESULTS: Out of fifty patients, structural pathology was found in ten. Nine out of these ten patients had small bowel involvement while seven had colonic involvement alone or in combination with small bowel involvement. The sensitivity of BMFTP was 100% compared to 88.89% with BMFT when detecting small bowel involvement (BMFTP detected one additional patient with ileocecal involvement). The sensitivity and specificity of BMFTP for the detection of colonic pathology were 85.71% and 95.35% (41/43), respectively. Screening a patient with chronic abdominal pain (bowel origin) using a combination of BMFT and barium enema cost significantly more than BMFTP while their sensitivity was almost comparable.

CONCLUSION: BMFTP should be included in the investigative workup of patients with chronic abdominal pain of luminal origin, where either multiple sites (small and large intestine) of involvement are suspected or the site is unclear on clinical grounds. BMFTP is an economical, quick and comfortable procedure which obviates the need for colonoscopy in the majority of patients.

Computed tomography enteroclysis in the diagnosis of intestinal diseases

The role of computed tomography (CT) enteroclysis in the imaging of small bowel diseases is expanded with recent technological advances in multidetector CT system. Computed tomography enteroclysis is the examination of choice for patients with symptoms of intermittent small bowel obstruction, especially when there is a history of prior complex abdominal surgery, abdominal tumor, radiation therapy, and also in high grade obstructions with suspicion of extraintestinal internal fistula. Computed tomography enteroclysis is becoming the first-line modality for the evaluation of advanced and complicated small bowel Crohn disease. Computed tomography enteroclysis can also become an important complementary imaging technique to capsule endoscopy in the assessment of small bowel neoplasms and occult gastrointestinal hemorrhage. In this study, the technique and clinical applications of CT enteroclysis are reviewed; its advantages and limitations compared with the other imaging techniques and capsule endoscopy are discussed.

Video capsule endoscopy in small-bowel tumours: a single centre experience

OBJECTIVE

Early diagnosis of small-bowel tumours is crucial for curative surgery. Although videocapsule endoscopy (VCE) has improved the diagnosis of small-bowel diseases, there are few data about the role of this examination in small-bowel malignancies. The aim of this study was to evaluate the diagnostic yield of VCE in small-bowel malignancies.

MATERIAL AND METHODS

From March 2001 to July 2006, 380 patients were studied by VCE in our centre. Data on 13 consecutive patients (3.4%) affected by small-bowel malignancy were retrospectively assessed from a prospectively collected database. Indications for VCE were: obscure gastrointestinal bleeding in 9 patients (70%), abdominal pain, coeliac disease, long-lasting fever and hepatic metastasis in the other 4 patients, respectively, (7.5%). Before VCE, patients had undergone 65 procedures, including oesophagogastroduodenoscopy, colonoscopy, push-enteroscopy, small-bowel radiographies, abdominal CT scanning, nuclear medicine bleeding-scan, positron emission tomography and octreoscan.

RESULTS

VCE detected jejunal polyps in 6 patients (46.2%), ulcerated stricture in 3 (23%), and erosions, stricture with ileal inflammation, submucosal nodule and active bleeding in 4 patients, respectively. The diagnosis was confirmed after surgery in 11 cases. One patient died of ischaemic myocardial infarction 3 days after VCE, before surgery. Histological examination showed lymphoma (n=3), small-bowel metastasis from colonic carcinoma (n=3), carcinoid tumour (n=3), gastrointestinal stromal tumour (GIST) (n=2), metastatic melanoma (n=1) and primary small-bowel adenocarcinoma (n=1). VCE had an influence on the diagnosis or management of 10/13 patients.

CONCLUSIONS

VCE is the diagnostic test with the highest yield for small-bowel malignancies, since it can detect small-bowel tumours that are often missed by traditional examinations.

CT Enteroclysis

Computed tomographic (CT) enteroclysis is a hybrid technique that combines the methods of fluoroscopic intubation-infusion small-bowel examinations with that of abdominal CT. The use of multidetector CT technology has made this a versatile examination that has evolved into two distinct technical modifications. CT enteroclysis can be performed by using positive enteral contrast material without intravenous contrast material and neutral enteral contrast material with intravenous contrast material. CT enteroclysis has been shown to be superior to other imaging tests such as peroral small-bowel examinations, conventional CT, and barium enteroclysis, except in the demonstration of early apthous ulcers of Crohn disease. CT enteroclysis is complementary to capsule endoscopy in the elective investigation of small-bowel disease, with a specific role in the investigation of Crohn disease, small-bowel obstruction, and unexplained gastrointestinal bleeding.

Clinical application and diagnostic yield of wireless capsule endoscopy in children

OBJECTIVE

The small bowel is anatomically difficult to examine and was investigated by invasive, indirect modalities, such as push enteroscopy and small bowel follow-through. The aim of this study was to assess the efficacy and clinical impact of wireless capsule endoscopy (WCE) in children.

MATERIALS AND METHODS

Over the last 3 years (2002-2005), 37 patients with suspected small-bowel disease were investigated with WCE at a median age of 11 years (range, 16 months-16 years). The indications for WCE was suspected Crohn's disease (CD) (18), obscure or occult gastrointestinal bleeding (7), polyposis syndromes (5), protein losing enteropathy (4), recurrent abdominal pain (2), and malabsorption syndrome (1). All patients had preceding upper gastrointestinal endoscopy (OGD), ileocolonoscopy, and 26 cases had a small bowel follow-through (SBFT). These results were compared with the findings on WCE.

RESULTS

Thirty-three (33) cases successfully completed the WCE through the small bowel. Four (4) patients were unable to swallow the capsule, 3 of which had to be placed in the duodenum endoscopically. In 3 patients, the capsule remained in the stomach and no small bowel images were obtained. The overall diagnostic yield was 85% (28/33 patients). The diagnostic findings included CD (13), source of gastrointestinal bleeding (7), polyposis syndromes (3), erosive enteropathy and patchy lymphangiectasia (4), and intussusception (1). WCE was found to be more sensitive for small bowel pathology than SBFT (20 vs. 6 [30% sensitivity, compared to WCE]) and endoscopic investigations (28 vs. 12 [43% sensitivity compared to WCE]). As a result of WCE findings, there was a positive alteration in the management in 28 of 33 (85%) cases.

CONCLUSIONS

WCE is a novel, noninvasive, and useful tool for the investigation of the small intestine in children. It is superior and more sensitive than other conventional endoscopic and radiologic investigations in the assessment of the small bowel. It can help in guiding surgical decisions and should be routinely integrated as a part of the diagnostic work-up of small bowel pathology.

Capsule enteroscopy and radiology of the small intestine

In a very few years, the video capsule for small bowel enteroscopy has gained widespread clinical acceptance. It is readily ingested, disposable, and allows for a complete, low-invasive endoscopic examination of the entire mucosa of the small bowel. It is a patient-friendly method and a first-line procedure in the difficult evaluation of obscure gastrointestinal bleeding. It has the highest proven figure of diagnostic sensitivity for detecting lesions of the mucosa, irrespective of aetiology. The limitations of capsule endoscopy include difficulty in localising mucosal lesions anatomically and its restricted use in patients with dysphagia, strictures or motor dysfunction. Strictures, transmural and extra-mural lesions in patients with small bowel Crohn's disease are evaluated by MRI- enterography and CT-enterography.

CT enteroclysis: techniques and applications

CT enteroclysis overcomes the individual deficiencies of both barium enteroclysis and conventional CT and combines the advantages of both into one technique whose clinical applicability has been simplified and made more reliable with multidetector CT technology. This article examines the techniques of CT enteroclysis and presents an overview of its clinical applications relative to other methods of small bowel imaging.

Small bowel capsule endoscopy: a systematic review

Wireless capsule endoscopy offers a revolutionary diagnostic tool for small bowel diseases. Since its formal introduction, it has become an integral part of the diagnostic evaluation for obscure gastrointestinal bleeding. This relatively noninvasive imaging modality offered by small bowel capsule endoscopy is appealing to both patients and providers and consequently, the desire to expand its diagnostic role continues to grow. The use of CE in the diagnosis of Crohn disease and chronic diarrhea is being further investigated, as is the potential of employing this technique as a cancer surveillance mechanism in patients with hereditary polyposis syndromes which may involve the small bowel. This review article discusses the current indications for small bowel capsule endoscopy, the results of capsule endoscopy in patients with obscure gastrointestinal bleeding and small bowel diseases, and patient outcomes following capsule endoscopy. Capsule endoscopy is compared with traditional diagnostic modalities, including small bowel series, enteroclysis, CT, and push enteroscopy. Small bowel capsule endoscopy is the procedure of choice to evaluate obscure gastrointestinal bleeding, and is superior to radiographic procedures in detecting Crohn disease of the small bowel.

Small-bowel tumors detected by wireless capsule endoscopy

Small bowel tumors are difficult to diagnose because of their endoscopic inaccessibility. This has been overcome by the use of the Pillcam SB capsule (Given Imaging, Yoqneam, Israel). The purpose of this report is to describe the largest series of patients with small bowel tumors detected by capsule endoscopy. Eighty six patients were derived from the Given Imaging clinical database on a survey of Pillcam SB capsule users who were diagnosed with 87 small bowel tumors, 1 cecal tumor, and 1 gastric tumor. The population consisted of 55 males and 31 females. 69% of patients were referred for capsule endoscopy for obscure gastrointestinal bleeding (59/86 patients) and 31% (27/86 patients) were referred for other indications including anemia, polyposis, and abdominal pain. All patients have histologically confirmed tumors. Eighty six patients reported 395 previous negative procedures (average of 4.6 per patient). Malignant tumors comprised 61% (54/89) and benign 39% (35/89). Of the 87 reported small bowel tumors, 4 were identified in the duodenum, 43 tumors were identified in the jejunum, 18 tumors were identified in the ileum, and 22 tumors were located in the mid to distal small bowel. The most common malignant tumors were adenocarcinoma, carcinoids, melanomas, lymphomas, and sarcomas. The most common benign tumors were GIST, hemangiomas, hamartomas, adenomas, and granulation tissue polyps. Capsule endoscopy is the diagnostic procedure of choice in patients with suspected small bowel tumors.

Small-bowel tumors detected by wireless capsule endoscopy

Small bowel tumors are difficult to diagnose because of their endoscopic inaccessibility. This has been overcome by the use of the Pillcam SB capsule (Given Imaging, Yoqneam, Israel). The purpose of this report is to describe the largest series of patients with small bowel tumors detected by capsule endoscopy. Eighty six patients were derived from the Given Imaging clinical database on a survey of Pillcam SB capsule users who were diagnosed with 87 small bowel tumors, 1 cecal tumor, and 1 gastric tumor. The population consisted of 55 males and 31 females. 69% of patients were referred for capsule endoscopy for obscure gastrointestinal bleeding (59/86 patients) and 31% (27/86 patients) were referred for other indications including anemia, polyposis, and abdominal pain. All patients have histologically confirmed tumors. Eighty six patients reported 395 previous negative procedures (average of 4.6 per patient). Malignant tumors comprised 61% (54/89) and benign 39% (35/89). Of the 87 reported small bowel tumors, 4 were identified in the duodenum, 43 tumors were identified in the jejunum, 18 tumors were identified in the ileum, and 22 tumors were located in the mid to distal small bowel. The most common malignant tumors were adenocarcinoma, carcinoids, melanomas, lymphomas, and sarcomas. The most common benign tumors were GIST, hemangiomas, hamartomas, adenomas, and granulation tissue polyps. Capsule endoscopy is the diagnostic procedure of choice in patients with suspected small bowel tumors.

The value of the per oral pneumocolon in the study of the distal ileal loops

AIM

To verify the diagnostic accuracy of per oral pneumocolon in the identification of both normal and pathological patterns in patients with suspected or proven small bowel disease.

MATERIALS AND METHODS

Per oral pneumocolon was performed after small bowel follow-through examinations in a series of 42 selected patients. The terminal ileum visibility, the loop location and possible pathological patterns were evaluated separately before and after insufflation. In post-insufflation images the presence/absence of reflux and grade of reflux were evaluated.

RESULTS

The diagnostic quality of per oral pneumocolon as compared with per oral small bowel examination was superior in 23 of the 42 patients (54.8%; group 1), similar in nine of the 42 (21.4%; group 2), and inferior in 10 of the 42 (23.8%; group 3). Transvalvular reflux was present in 22 of 23 (95.6%) patients from group 1 and only in one of 10 patients (10%) from group 3 (p<0.001: statistically significant difference). Among the 24 of 42 (57.1%) patients with suspected or proven Crohn's disease, per oral pneumocolon increased the confidence with which the ileum was considered normal in 12 patients and it allowed a better evaluation of the disease extent and the differentiation between prolonged spasms and stenosis in five patients.

CONCLUSION

In conclusion per oral pneumocolon should be performed after a small bowel follow-through examination in selected patients.

Video capsule endoscopy compared with standard endoscopy for the evaluation of small-bowel polyps in persons with familial adenomatous polyposis (with video)

BACKGROUND

Video capsule endoscopy (VCE) may be useful for surveillance of small-bowel polyps in patients with familial adenomatous polyposis (FAP).

OBJECTIVE

To compare VCE to standard endoscopy for diagnosing small-bowel polyps in a defined segment of small bowel (proximal to a tattoo) and the entire examined small bowel.

DESIGN

Prospective.

SETTING

Single tertiary referral center.

PATIENTS

Participants with FAP (n = 32). The majority were selected for their high number of proximal small-bowel polyps and prior endoscopic tattoo placement in the proximal small bowel.

INTERVENTIONS

VCE (interpreted by 2 readers), push enteroscopy (PE), and lower endoscopy (LE) to count and measure small-bowel polyps.

RESULTS

In the defined segment, VCE detected a median of 10.0 (interquartile range [IQR], 5.0-19.0) and 9.0 (IQR, 6.0-16.0) polyps for each reader compared with a median of 41.0 (IQR, 19.0-64.0) polyps on PE (P = .002). Agreement between the 2 methods was fair (kappa = 0.34, 0.36). Agreement between VCE and PE was poor to fair (kappa = 0.10, 0.22) for estimating the size of the largest polyp and poor (kappa = -0.20, -0.27) for detecting large polyps (> or =1 cm). In the entire examined small bowel, VCE diagnosed a median of 38.0 (IQR, 10.5-71.5) and 54.0 (IQR, 13.0-100.0) polyps for each reader compared with a median of 123.0 (IQR, 38.5-183.0) for combination endoscopy (PE and LE) (P < .001). Agreement between the 2 methods was fair to moderate (kappa = 0.21, 0.56).

LIMITATIONS

Participants selected for high polyp burden, and results may not be applicable to all patients with FAP.

CONCLUSIONS

VCE underestimates the number of small-bowel polyps in persons with FAP and does not reliably detect large polyps.

Palliating Patients Who Have Unresectable Colorectal Cancer: Creating the Right Framework and Salient Symptom Management

The last phases of colorectal malignant illness may be the most challenging and saddening for all involved, but they offer opportunities to become the most rewarding. This transformation of hopelessness to fulfillment requires a willingness by surgeon, patient, and patient's family to trust one another to realistically set goals of care, stick together, and not let the treatment of the disease become a surrogate for treating the suffering that characterizes grave illness.

Small bowel tumors

WCE is a noninvasive diagnostic technique that visualizes the entire small intestine and identifies lesions in parts of the small bowel not reached by traditional endoscopy. Although further studies are needed to define the exact role of WCE for diagnosing and managing small bowel tumors, its sensitivity has been shown to be superior to PE and small bowel follow-through in regard to diagnosing patients who have obscure GI bleeding, the most common indication for capsule endoscopy in the authors' series of patients with documented small bowel tumors. As more material is published, capsule endoscopy likely will be confirmed to be the diagnostic procedure of choice in patients with suspected small bowel tumors.

Multislice CT enteroclysis: technique and clinical applications

Computed tomography (CT) enteroclysis was introduced to overcome the individual deficiencies of barium enteroclysis and abdominal CT. The use of multislice CT technology has made the procedure a feasible extension of the intubation infusion method of small bowel examination. This review is an update of the technique and clinical application of CT enteroclysis with illustrations.

Obscure gastrointestinal bleeding

Obscure GI bleeding is a relatively common problem facing internists, gastroenterologists, and surgeons in a typical clinical practice. The etiology is occasionally suggested by the patient's age, history, and medications. Management is complicated and typically requires a team-oriented approach, with input from the internist, gastroenterologist, radiologist, and surgeon alike. SBFT and enteroclysis seem to have a limited role, unless there is a high suspicion of a small bowel mass lesion or Crohn's disease. Scintigraphy may be performed in patients with active bleeding in whom endoscopy has failed oris contraindicated. Angiography may be used in patients with an early positive nuclear imaging or failed endoscopic therapy. Provocative angiography probably has a lower diagnostic yield than previously reported, and should be performed only in experienced centers. Helical CT is a new and potentially important option in patients with obscure bleeding, but is currently considered experimental. All patients with obscure GI bleeding should undergo repeat upper endoscopy and perhaps colonoscopy to rule out missed lesions. SBE seems to be complementary to capsule endoscopy, and it is unknown whether this should be performed before capsule endoscopy or only if capsule endoscopy yields a positive proximal small bowel finding. Double balloon enteroscopy seems promising, but the technique requires further study. Surgery should be reserved for patients who have a positive capsule endoscopy requiring surgical therapy or patients who have persistent GI bleeding requiring recurrent blood transfusions in whom all other modalities have failed. Treatment for vascularectasias, the most common cause of obscure GI bleeding, is currently inadequate,and typically requires a combination of multiple management approaches.

The evolution of endoscopy: wireless capsule cameras for the diagnosis of occult gastrointestinal bleeding and inflammatory bowel disease

Occult gastrointestinal bleeding and lesions associated with inflammatory bowel disease represent a diagnostic dilemma because they often lie in areas of the small bowel that are difficult to access with flexible fiberoptic endoscopy. Capsule endoscopy has been developed to access these areas in a way that avoids the pain and anesthesia risks of push endoscopy. The diagnostic yield of capsule endoscopy has proven to be superior to both flexible small-bowel endoscopy and radiologic studies in several prospective trials. Capsule endoscopy transmits a large number of images that do not correlate well with the standard endoscopic view, creating a diagnostic challenge for the endoscopist. Complications of this procedure include capsule retention in diverticulae or at stricture sites. The technology of this procedure continues to evolve through improving image resolution and diagnostic accuracy. Capsule endoscopy also represents an overall economic saving despite a high unit price compared with the expense of repeat diagnostic testing. Because the diagnostic yield of capsule endoscopy is nearly twofold greater than conventional endoscopy, it has become the procedure of choice for the dilemma of assessing small-bowel pathology for many clinicians. Further studies are needed to determine whether the capsule endoscope can replace conventional endoscopy in the first-line diagnosis of pathology in other parts of the alimentary tract.

Radiology of small bowel obstruction: contemporary approach and controversies

The radiologic workup of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this complex situation have undergone considerable changes over the past two decades. The diagnosis and treatment of small bowel obstruction, a common clinical condition often associated with signs and symptoms similar to those seen in other acute abdominal disorders, continue to evolve. This article examines the changes related to the use of imaging in the diagnosis and management of patients with this potentially dangerous problem and revisits pertinent controversies.

Diagnostic yield and clinical outcomes of capsule endoscopy

BACKGROUND

Capsule endoscopy is proving to be superior to push enteroscopy and barium contrast radiography for evaluation of the small bowel. However, its impact on clinical outcome has not been thoroughly investigated. This study assessed changes in therapy based on capsule endoscopy findings and on the impact of such changes on patient outcomes.

METHODS

Forty-four consecutive capsule endoscopies in 43 patients were reviewed. Data were collected by systematic review of patient records and included indication, results of prior diagnostic tests, and capsule endoscopy findings. Specific interventions after capsule endoscopy and clinical outcome were noted.

RESULTS

The indication for capsule endoscopy was obscure GI bleeding in 40 patients, iron deficiency anemia in one, and right lower quadrant abdominal pain in two patients. Overall diagnostic yield was 42% (18/43 patients). Diagnostic findings included angiodysplasias (n = 13), intestinal ulcers (n = 2), Crohn's disease (n = 2), and mass lesion (n = 1). As a result of the capsule endoscopy findings, a specific intervention was implemented in 12 of 18 patients with positive findings. These included endoscopy with coagulation (n = 5), laparotomy (n = 2), pharmacotherapy (n = 4), and discontinuation of medication (n = 1). At a mean follow-up of 6.7 months, the clinical outcome was considered positive in 7 of 43 patients (16%).

CONCLUSIONS

Although it has a high diagnostic yield, capsule endoscopy has a positive influence on clinical outcome in a relatively small proportion of patients. Larger studies are needed that assess the influence of capsule endoscopy on clinical outcomes.

Multidetector CT enteroclysis: comparison of the reading performance for axial and coronal views

The purpose of this study was to compare the diagnostic performance of axial and coronal views in multidetector CT enteroclysis (MDCTE). We retrospectively evaluated 48 patients with pathological correlation investigated by MDCTE for small bowel disorders. After nasojejunal administration of 2 l of 5% methylcellulose axial arterial and venous acquisition of MDCTE was followed by coronal reconstructions using equal slice thicknesses of 2.5 mm with 2 mm increments. Spatial resolution of both planes was evaluated by phantom. Three radiologists independently read axial and coronal images concerning 12 pathological features. The interobserver agreement and time of reading was calculated. Sensitivity and specificity resulted from comparison with histopathology (n=39) or follow-up (n=9). Phantom study revealed higher spatial resolution for axial than coronal views, whatever reconstruction interval was used. However, spatial frequency always remained high. Most pathological signs, such as bowel wall thickening (BWT), bowel wall enhancement (BWE) and intraperitoneal fluid (IPF), showed better interobserver agreement on axial than coronal views (BWT: 0.61 vs. 0.44; BWE: 0.56 vs. 0.5; IPF:0.53 vs. 0.43). The Wilcoxon signed-rank test revealed significantly higher sensitivity for axial than coronal views (P=0.0453); the time of reading was significantly shorter for the latter (P=0.0146). The diagnostic value of axial slices is superior to coronal reconstructions despite the reduced data volume and display of the physiological course of bowel loops on the coronal plane.

Mr enteroclysis using iron oxide particles (ferristene) as an endoluminal contrast agent: An open phase III trial

To evaluate efficacy and safety of a superparamagnetic iron oxide contrast agent (ferristene) as an endoluminal contrast medium for magnetic resonance (MR) enteroclysis in a phase III trial. Twenty-three patients with history of known or suspected small bowel Crohn's disease underwent MR imaging of the abdomen at 0.5 T unit. The imaging protocol included two phases: the first one without administration of any contrast agent and the second one, where the small bowel was filled by enteroclysis with 800 ml of the luminal iron oxide contrast medium and Gd-DTPA (0.1 mmol/Kg) was administered intravenously. Axial Spin-Echo (SE) T1-weighted (T1w), proton-density and T2w images, sagittal and coronal SE T1w and Short TI Inversion Recovery (STIR) sequences were subsequently obtained. Three investigators blindly evaluated images to determine small bowel distribution of ferristene, presence of artifacts, delineation of bowel lesion/wall and the diagnostic value of ferristene combined with gadolinium. Pre- and postcontrast signal intensity measurements of bowel lesion/wall, bowel lumen and background noise were also calculated. Three patients withdrew before the procedure, therefore 20 patients were effectively included in the study. No significant difference between the three investigators' evaluations of the improvement of the diagnostic information was found (percentage of improvement of 90% with 95% confidence limits of 68% and 99%). A statistically significant difference between the first and third investigators was found for grading of quality of delineation of bowel lesion/wall. Signal intensity measures showed a significant increase of the bowel lesion/wall and background noise/lesion for the SE T1w images. No serious adverse event was reported in our series. MR enteroclysis using ferristene as an endoluminal contrast agent appears to be a safe and efficient procedure for the study of the small bowel.

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