Capsule endoscopy for the evaluation of nonsteroidal anti-inflammatory drug-induced enteropathy: United Kingdom pilot data

Patency testing improves capsule retention rates but at what cost? A retrospective look at patency testing

Capsule retention is one of the major complications of capsule endoscopy, which range from 2.1 to 8.2% depending on the indication. Over the last few years, reported rates of retention have fallen due to better patient selection due to the recognition of risk factors for capsule retention as well as the introduction of the patency capsule. The patency capsule is a dissolvable capsule with the same dimensions as the functional capsule. It breaks down in the GI tract after approximately 30 h, reducing the risk of symptomatic retention. Failure to pass this patency capsule out of the small bowel results in the patient being excluded from capsule endoscopy. We performed a retrospective analysis of the patency capsules performed in our unit over a 12-month period. A total of 166 (14.7%) of 1,127 patients referred for capsule endoscopy were deemed to require patency assessment (45.8% men, mean age 48 years). Of those who passed the patency assessment and underwent capsule endoscopy, no capsule retention was seen. Indication for patency assessment was found to be appropriate in 87.0% (n = 147). Overall, the failure rate at the patency assessment was 43.1%. The patency capsule remains an imperfect but useful tool in examining functional patency of the GI tract prior to capsule endoscopy.

Indications and Limitations Associated with the Patency Capsule Prior to Capsule Endoscopy

The retention of the capsule used during small bowel capsule endoscopy (SBCE) is a serious complication that can occur in patients with known or suspected small bowel stenosis, and a prior evaluation of the patency of the gastrointestinal (GI) tract is therefore essential. Patency capsule (PC) is a non-diagnostic capsule the same size as the diagnostic SBCE. To date, there are no clear guidelines regarding the contraindications for undergoing a PC evaluation prior to SBCE. Each small bowel disorder has specific occasions to inhibit the progress of PC and SBCE, even though they do not have any stenotic symptoms or abnormalities on imaging. In this review, we summarize the indications and limitations of PC prior to SBCE, especially the contraindications, and discuss clinical scenarios in which even PC should be avoided, and therefore such areas of stenosis should be evaluated by alternative modalities. We thus propose this new algorithm to evaluate the patency of the GI tract for patients with suspected and known small bowel stenosis in order that they may undergo SBCE safely.

Capsule endoscopy: Current status and role in Crohn's disease

Capsule endoscopy (CE) has proved to be an important non-invasive tool for diagnosis and monitoring Crohn's disease patients. It has the advantage of excellent visualization of digestive tract mucosa, a good tolerability and safety in well-selected patients. The risk of retention can be diminished by good selection of patients using imaging techniques and by the use of patency capsule. The aim of a capsule examination is not only an early diagnosis but also a very good stratification of prognosis, thus directing the treatment strategy for either a step up or top-down approach and also permitting the optimization of the treatment depending on the findings. When symptoms and biomarkers point to a change in the disease's activity we can either adjust the treatment directly as recommended in CALM study or choose in selected patients to visualize the digestive mucosa through a CE and take a decision afterwards. The appearance of the new capsule from Medtronic-the Pillcam Crohn's might be an important step forward in diagnosis, evaluating disease extent, the severity of the disease, prognosis, management in a treat to target approach, with treatment modifications according to the data from CE examination. Serial examinations in the same patient can be compared and a more objective evaluation of the lesions modification from one exam to another can be performed. We present the latest developments and current status and evidence that in selected patients capsule can be a tool in a treat to target approach.

Non-steroidal Anti-inflammatory Drug Induced Injury to the Small Intestine

Non-steroidal anti-inflammatory drug (NSAIDs) induced enteropathy represents an important complication of one of the most commonly used drugs worldwide. Due to previous diagnostics difficulties the real prevalence of this disease was underestimated for a long time. The pathogenesis of NSAID-enteropathy is more multifactorial and complex than formerly assumed but has still not been fully uncovered. A combination of the local and systemic effect plays an important role in pathogenesis. Thanks to novel enteroscopy methods (wireless capsule endoscopy, double balloon enteroscopy), small bowel lesions are described in a substantial section of NSAID users although most are clinically asymptomatic. The other non-invasive tests (small bowel permeability, faecal calprotectin, scintigraphy using faecal excretion of 111-indium-labelled leukocytes etc.) proposed for diagnostics are not generally used in clinical practice, mainly because of their non-specificity. Despite intensive research into possible treatment, the main measure for patients with NSAID-enteropathy is still withdrawal of NSAIDs. Double balloon enteroscopy plays an important role in the treatment of complications (bleeding, strictures).

Retention during capsule endoscopy: Is it a real problem in routine practice?

OBJECTIVE

This study evaluated the risks and outcomes of capsule retention during capsule endoscopy (CE) for investigating small bowel disease. Capsule retention is the most serious complication of CE.

METHODS

Before CE, the gastrointestinal tract was evaluated for blockages with computerized tomography. Analysis of CE was made retrospectively.

RESULTS

Capsule endoscopy was used to investigate obscure bleeding (90.2%; n = 324) or other symptoms (9.8%; n = 35). The capsule retention rate was 11/359 (3.1%); it was retained in a malignant lesion area (adenocarcinoma or melanoma) in two patients (18.2%), in the small bowel in an ulcerated area in five patients (45.5%), and in the oesophagus/stomach in four patients (36.4%) due to dysmotility. None of the patients had symptoms of obstruction.

CONCLUSIONS

Scanning patients before CE did not predict capsule retention. Retention is a complication of CE, but occurs as a result of the underlying disease. The risk of retention is increased in patients with motility disorders, suspected small bowel ulcers or malignancies.

Autophagy Deficiency Diminishes Indomethacin-Induced Intestinal Epithelial Cell Damage through Activation of the ERK/Nrf2/HO-1 Pathway

Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause epithelial cell damage in the stomach, intestine, and colon. NSAIDs are reported to induce autophagy and apoptosis in intestinal epithelial cells; however, their role in cell damage is poorly understood. To examine the role of autophagy in cell damage, we used autophagy-related gene Atg5-conditional knockout mice, in which the Atg5 gene is only knocked out in intestinal epithelial cells. In an indomethacin (IM)-induced gastrointestinal ulcer mouse model, intestinal epithelium damage was reduced in Atg5-conditional knockout mice compared with wild-type mice. IM-induced damage in IEC6 rat intestinal epithelial cells was reduced when Atg5 was silenced (IEC6shAtg5 cells). Western blot analyses indicated that IM-induced apoptosis decreased, and the potent, oxidative stress-related extracellular signal-regulated kinase (ERK)/nuclear factor-erythroid2-like2 (Nrf2)/heme oxygenase-1 (HO-1) signaling pathway was upregulated in IEC6shAtg5 cells. An experiment using a reactive oxygen species (ROS)-sensitive fluorescent dye in IEC6shAtg5 cells revealed that the amount of ROS at the baseline and the rate of increase after IM treatment were lower than in intact IEC6 cells. The mitochondrial membrane potential at the baseline and the reduction rate in IM-treated IEC6shAtg5 cells were lower than in intact IEC6 cells, indicating that autophagy deficiency increased ROS production caused by mitochondrial disturbance. Furthermore, MnTMPyP, a manganese-superoxide dismutase mimetic, significantly inhibited IM-induced autophagy and subsequent apoptosis as well as activation of the ERK/Nrf2/HO-1 pathway. These data suggest that autophagy deficiency and subsequent activation of the ERK/Nrf2/HO-1 pathway diminished IM-induced, apoptosis-mediated intestinal epithelial cell damage, and genetic analyses of single nucleotide polymorphisms in autophagy-related genes could predict NSAID-induced intestinal injury.

Protective effect of rabamipide on non-steroid anti-inflammatory drug induced enteropathy in rats

AIM: To investigate the effect of rabamipide on non-steroid anti-inflammatory drug (NSAID) induced enteropathy in rats and the possible mechanism.

METHODS: Thirty male Sprague-Dawley rats were randomized into three groups: a control group, a diclofenac induced injury group, and a rabamipide pretreatment group. Intestinal injury was induced in rats of the diclofenac induced injury group and rabamipide pretreatment group by intragastric administration of diclofenac (7.5 mg/kg) once per day for continuous 4 d. The rabamipide pretreatment group was pretreated with rabamipide 100 mg/(kg•d) orally once daily 1 h before the administration of diclofenac. The control group received 0.9% NaCl by gavage during the same period. All the rats were sacrificed on the 4^th day. Small intestinal injuries were assessed for histopathological damage and macroscopic injury and recorded as corresponding scores. Immunohistochemistry and Western blot were used to detect the distribution and expression of intestinal epithelial tight junction protein occludin. The expression of ERK, p38, phosphorylated ERK (p-ERK) and phosphorylated p38 (p-p38) was determined by Western blot.

RESULTS: Compared with the control group, histopathological and macroscopic scores of intestinal damage were significantly increased in the diclofenac induced injury group (P < 0.05). Intestinal damage scores in the rabamipide pretreatment group were significantly decreased compared with those in the diclofenac induced injury group (P < 0.05). Compared with the control group, expression of occludin in the diclofenac induced injury group was decreased significantly (P < 0.05), while that in the rabamipide pretreatment group increased significantly compared with the diclofenac induced injury group (P < 0.05). Significant activation of ERK and p38 was seen in the diclofenac induced injury group compared with the control group (P < 0.05), and pretreatment with rabamipide significantly inhibited the activation of ERK and p38 compared with the diclofenac induced injury group (P < 0.05).

CONCLUSION: Rabamipide has a protective effect on NSAID induced enteropathy in rats, probably by increasing the expression of occludin protein and inhibiting the activation of ERK as well as p38 signaling pathways.

Diagnostic modalities for the evaluation of small bowel disorders

PURPOSE OF REVIEW

This review summarizes the recent developments in the evaluation of small bowel disorders using videocapsule endoscopy (VCE) and serological and breath-test biomarkers.

RECENT FINDINGS

The ability to visualize the small bowel was revolutionized with the introduction of VCE technology. VCE allows for accurate, noninvasive visualization of the small bowel mucosa. This device is invaluable in the investigation of obscure gastrointestinal bleeding (OGIB), occult bleeding with iron deficiency anaemia, small bowel Crohn's disease (CD), small bowel neoplasms and other mucosal disorders. Recent studies underscored the utility of VCE for documenting the extent and severity of small bowel CD as well as monitoring activity after therapy. The accuracy of the discrimination between small bowel tumours and benign bulges has been improved by a novel endoscopic algorithm. The accuracy of VCE was also evaluated as a potential noninvasive alternative to small bowel biopsies in suspected celiac disease. New findings have been made using breath tests and other biomarkers for the diagnosis of celiac disease, irritable bowel syndrome and bacterial overgrowth.

SUMMARY

VCE as well as breath-test biomarkers play a major and expanding role in the diagnosis and monitoring of various small bowel disorders.

Role of capsule endoscopy in inflammatory bowel disease

Videocapsule endoscopy (VCE) has revolutionized our ability to visualize the small bowel mucosa. This modality is a valuable tool for the diagnosis of obscure small bowel Crohn’s disease (CD), and can also be used for monitoring of disease activity in patients with established small-bowel CD, detection of complications such as obscure bleeding and neoplasms, evaluation of response to anti-inflammatory treatment and postoperative recurrence following small bowel resection. VCE could also be an important tool in the management of patients with unclassified inflammatory bowel disease, potentially resulting in reclassification of these patients as having CD. Reports on postoperative monitoring and evaluation of patients with ileal pouch-anal anastomosis who have developed pouchitis have recenty been published. Monitoring of colonic inflammatory activity in patients with ulcerative colitis using the recently developed colonic capsule has also been reported. Capsule endoscopy is associated with an excellent safety profile. Although retention risk is increased in patients with small bowel CD, this risk can be significanty decreased by a routine utilization of a dissolvable patency capsule preceding the ingestion of the diagnostic capsule. This paper contains an overview of the current and future clinical applications of capsule endoscopy in inflammatory bowel disease.

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.

Proton pump inhibitors are not the key for therapying non-steroidal anti-inflammatory drugs-induced small intestinal injury

The ability of non-steroidal anti-inflammatory drugs (NSAIDs) to injure the small intestine has been well established in humans and animals. Proton pump inhibitors (PPIs) are frequently prescribed to reduce gastric and duodenal injury caused in high-risk patients taking NSAIDs. However, scarce information is available concerning the effects of PPIs on intestinal damage induced by NSAIDs, and the suppression of gastric acid secretion by PPIs is hard to provide any protection against the damage caused by NSAIDs in the small intestine. The present study was designed to examine the effects of intragastric treatment of two PPIs widely used in clinical practice, namely omeprazole and pantoprazole, on the intestinal damage induced by administration of diclofenac in rat. Male SD rats were treated with omeprazole or pantoprazole for 9 days, with concomitant treatment with anti-inflammatory doses of diclofenac on the final 5 days. The anatomical lesion, villous height, the thickness, and the section area of small intestine were quantitatively analyzed. The change of ultrastructural organization was observed. Endotoxin level in blood was measured by photometry. Epidermal growth factor was observed by immunohistochemistry. Omeprazole and pantoprazole didn't decrease the macroscopic and histologic damage induced by diclofenac in the rat's small intestine. In the two PPI groups, villous height was (89.6 ± 11.8 and 92.6 ± 19.3 μm) lower than which of the control group (P < 0.05). The thickness became thinning, and the section area became small. LPS levels in the portal blood of omeprazole and pantoprazole were (4.36 ± 1.26 and 4.25 ± 1.17 EU/ml), significantly higher than in controls (P < 0.05). The EFG of PPI group descended significantly compared with the control group (P < 0.05). Omeprazole and pantoprazole cannot protect the small intestine from the damage induced by diclofenac in the conscious rat. PPIs cannot repair NSAID-induced intestinal damage at least in part because of significant lesion in mechanical barrier function and reduction in epidermal growth factor.

Therapeutic effects of muscovite to non-steroidal anti-inflammatory drugs-induced small intestinal disease

OBJECTIVE/BACKGROUND

The ability of non-steroidal anti-inflammatory drugs (NSAIDs) to injure the small intestine has been well established in humans and animals. Muscovite is one kind of natural clay consisting of an insoluble double silicate of aluminum and magnesium. It has been developed and marketed in China for the treatment of gastric diseases. The present study was designed to examine the effects of intragastric treatment of muscovite on the intestinal damage induced by administration of diclofenac in rat.

METHODS

Male SD rats were treated with muscovite for 9 days, with concomitant treatment with anti-inflammatory doses of diclofenac on the final 5 days. The anatomical lesion, villous height, the thickness and the section area of small intestine were quantitatively analyzed. The change of ultrastructural organization was observed. Endotoxin level in blood was measured by photometry. Epidermal growth factor was observed by immunohistochemistry.

RESULTS

Muscovite decreased the macroscopic and histologic damage induced by diclofenac in the rat small intestine. In the muscovite group, villous height (139.8±13.2 μm) was higher than which of the model group (86.6±17.1 μm) (P<0.05). The index of the thickness and the section area was higher than model group. LPS level in the portal blood of muscovite (0.84±1.17 EU/ml) was lower than model group (4.52±0.98 EU/ml) (P<0.05). The EFG of muscovite group was higher significantly compared with the model group (P<0.05).

CONCLUSION

Muscovite can protect the small intestine from the damage induced by diclofenac in the conscious rat. Muscovite can repair NSAID-induced intestinal damage at least in part because of significant lesion in mechanical barrier function and reduction in epidermal growth factor.

Isolated terminal ileal ulcerations in asymptomatic individuals: natural course and clinical significance

BACKGROUND

Although isolated terminal ileal ulcerations (ITIUs) are occasionally observed on colonoscopic examination of asymptomatic individuals, their clinical course and guidelines for treatment are unclear.

OBJECTIVE

To evaluate the clinical course and significance of ITIUs in asymptomatic individuals.

DESIGN

Single-center retrospective analysis.

SETTING

University hospital.

PATIENTS AND INTERVENTIONS

All patients diagnosed with ITIUs on colonoscopy from July 2001 to December 2007 were identified. Patients with colorectal symptoms, a history of nonsteroidal anti-inflammatory drug consumption, a history of colorectal surgery, oral or genital ulcerations, and coincidental ulceration in the ileocecal valve or colon were excluded.

MAIN OUTCOME MEASUREMENTS

Colonoscopic findings and clinical courses of patients were analyzed.

RESULTS

Of the 148 included patients, 93 were followed (mean duration, 29.9 months). Of these, 62 showed resolution of ITIU on follow-up colonoscopy, including 60 who resolved without any treatment and 2 who resolved after antituberculosis medication. Follow-up colonoscopy continued to show ITIUs in the remaining 31 patients, only 1 of whom developed typical Crohn's disease, whereas the other 30 showed no significant changes in the lesions (n = 22), partial improvement (n = 6), or waxing and waning endoscopic appearance (n = 2).

LIMITATIONS

Retrospective design, relatively short-term follow-up.

CONCLUSIONS

Most ITIUs incidentally observed in asymptomatic individuals resolve without any treatment. Even if these lesions persist, it is unusual for them to progress or to cause any symptoms.

Undisclosed use of nonsteroidal anti-inflammatory drugs may underlie small-bowel injury observed by capsule endoscopy

BACKGROUND & AIMS

Findings from capsule endoscopies (CEs) of patients with enteropathy from nonsteroidal anti-inflammatory drugs (NSAIDs) may be indistinguishable from those with Crohn's disease, making medication history crucial to image interpretation. Undeclared NSAID use has been proposed to cause unexplained peptic ulcers; we investigated whether it is also an issue among patients referred for small-bowel CE.

METHODS

We collected demographic data, indications for CE, and medication history prospectively. A salicylate spot test and gas chromatography-mass spectrometry were performed for NSAID metabolites in urine samples of patients undergoing routine CE. Videos were analyzed by a gastroenterologist who was blinded to the urinalysis results.

RESULTS

Seventy-six patients (52 women; mean age, 50 y) underwent CE for suspected small-bowel pathology. Urinalysis was positive in 13.6% of patients (salicylates, n = 3; ibuprofen, n = 6; and ibuprofen and diclofenac, n = 1) although only 1 of these patients declared use of an NSAID (aspirin). Although 2 patients had normal CE results, 80% had positive results, including the presence of erosions (n = 5), ulceration (n = 2), and ulcers with early stricturing (n = 1, diagnosed with Crohn's disease). A patient with small-bowel ulceration underwent surgery and was found to have NSAID-associated enteropathy, based on histologic analysis.

CONCLUSIONS

Of patients who undergo CE, 13.6% took NSAIDs or aspirin, but most did not declare using these medications. Small-bowel inflammation was common in this cohort and could be mistaken for Crohn's disease. Patients should be questioned about use of over-the-counter medications, and routine urinalysis for NSAID metabolites may be helpful before interpretation of CE findings.

Wireless capsule endoscopy in enteropathy induced by nonsteroidal anti-inflammatory drugs in pigs

AIM

The aim of this study is to evaluate the diagnostic yield of capsule endoscopy in nonsteroidal anti-inflammatory drug (NSAID)-induced enteropathy in pigs.

MATERIALS AND METHODS

Indomethacin (400 mg/day) was administrated orally for 10 days to eight female pigs weighing 36.3+/-2.4 kg. Afterwards, capsule endoscopy was performed, using the EndoCapsule system (Olympus Optical Co., Tokyo, Japan). The following morning, pharmacological euthanasia and immediate autopsy were performed.

RESULTS

Small bowel injury compatible with NSAID-induced enteropathy was observed in 7/8 animals. The most common lesions were red spots and erosions. Ulcers and small intestinal bleeding were identified sporadically. Sensitivity and specificity of capsule endoscopy were 83.3% and 95.8%, respectively.

CONCLUSION

Our results indicate that wireless capsule endoscopy is a highly accurate noninvasive method for evaluation of experimental NSAID-induced enteropathy.

Efficacy of rebamipide for diclofenac-induced small-intestinal mucosal injuries in healthy subjects: a prospective, randomized, double-blinded, placebo-controlled, cross-over study

BACKGROUND

Although obscure gastrointestinal bleeding cannot be detected by colonoscopy or upper endoscopy, wireless video capsule endoscopy (VCE) is capable of imaging it. Few data are available on medical therapy for patients with nonsteroidal anti-inflammatory drug (NSAID)-induced small-intestinal mucosal injuries. The aim of this study was to compare prevention by rebamipide and placebo of NSAID-induced smallintestinal injury in healthy subjects.

METHODS

Ten healthy subjects who provided written informed consent were enrolled. Rebamipide or placebo plus diclofenac was administered with omeprazole for 7 days, and for an additional 7-day period with treatments reversed in the same subjects, with a 4-week washout period between treatments. VCE of the small intestine was performed four times, before and after each of the two study periods.

RESULTS

The number of subjects with small-intestinal mucosal injuries was higher in the placebo group (8/10) than in the rebamipide group (2/10) (P = 0.023). Two cases of ulcer and one of bleeding were observed in the placebo group, while no ulcer or bleeding was observed in the rebamipide group.

CONCLUSIONS

Rebamipide had significantly higher efficacy than placebo in preventing NSAID-induced small-intestinal mucosal injury.