Review article: The advent of capsule endoscopy--a not-so-futuristic approach to obscure gastrointestinal bleeding

Could Capsule Endoscopy Be Useful in Detection of Suspected Small Bowel Bleeding and IBD-10 Years of Single Center Experience

A retrospective study in patients who underwent video capsule endoscopy (VCE) between 2006 and 2016 was conducted in the Clinic for gastroenterology and Hepatology, University Clinical Center of Serbia. A total of 245 patients underwent VCE. In 198 patients the indication was obscure gastrointestinal bleeding (OGIB), with 92 patients having overt and the other 106 occult bleeding. The remaining 47 patients underwent VCE due to suspected small bowel (SB) disease (i.e., Von Hippel-Lindau syndrome, familial adenomatous polyposis, Peutz Jeghers syndrome, Crohn's disease, prolonged diarrhea, abdominal pain, congenital lymphangiectasia, protein-losing enteropathy, tumors, refractory celiac disease, etc.). VCE identified a source of bleeding in 38.9% of patients (in the obscure overt group in 48.9% of patients, and in the obscure occult group in 30.2% of patients). The most common findings were angiodysplasias, tumors, Meckel's diverticulum and Crohn's disease. In the smaller group of patients with an indication other than OGIB, 38.3% of patients had positive VCE findings. The most common indication is OGIB, and the best candidates are patients with overt bleeding; patients with IBD should be evaluated in this setting.

Small bowel endoscopy in 2013: the reality and the potential

2013 saw several advances in small bowel endoscopy: new 3D visualization software, increased battery life, side-viewing cameras and higher frame rate. Studies on prokinetics for patient preparation, safety in the elderly, rebleeding after negative capsule endoscopy and defining optimum training requirements for fellows were encouraging. Procedure time and small bowel length evaluated by double-balloon and spiral endoscopy were shown to be comparable.

Therapeutic management options for patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is one of the most challenging disorders faced by gastroenterologists because of its evasive nature and difficulty in identifying the exact source of bleeding. Recent technological advances such as video capsule endoscopy and small bowel deep enteroscopy have revolutionized the diagnosis and management of patients with OGIB. In this paper, we review the various diagnostic and therapeutic options available for the management of patients with OGIB.

Outcomes associated with deep enteroscopy

The purpose of this article is to describe the available data regarding the short- and long-term outcomes associated with deep enteroscopy. Deep enteroscopy can be defined as the use of an enteroscope to examine small bowel distal to the ligament of Treitz or proximal to the distal ileum. The term deep enteroscopy includes double-balloon, single-balloon, and spiral enteroscopy. Comparisons are made with push enteroscopy and intraoperative enteroscopy, the major therapeutic endoscopic options available to the gastroenterologist before the introduction of deep enteroscopy. The article concludes with a discussion regarding complications associated with deep enteroscopy and cost-effectiveness of management strategies for obscure bleeding. Proposed changes to the current algorithm for management of obscure bleeding are suggested.

A validation study of 3 grading systems to evaluate small-bowel cleansing for wireless capsule endoscopy: a quantitative index, a qualitative evaluation, and an overall adequacy assessment

BACKGROUND

Capsule endoscopy (CE) is a powerful tool for evaluating the small bowel. Assessment of small-bowel cleansing for CE is an essential quality measure.

OBJECTIVE

Our purpose was to validate 3 new scales that grade small-bowel cleansing for CE.

DESIGN

Prospective, randomized, single-center study.

SETTING

Tertiary university hospital.

INTERVENTION

Five experienced capsule endoscopists read 40 CEs twice, separated by 1 month, to grade small-bowel cleansing on 3 scales-quantitative index (QI; 0-10), qualitative evaluation (QE; poor, fair, good, excellent), and overall adequacy assessment (OAA; inadequate, adequate). The QI and QE evaluated both the entire and distal small bowel. Investigators received no prior training in these scales.

MAIN OUTCOME MEASUREMENTS

Intraclass correlation coefficients to assess intraobserver (test-retest) and interobserver reliability.

PATIENTS

Forty patients who underwent 1 CE between June 2005 and May 2006 and who satisfied entry criteria.

RESULTS

Intraobserver reliability was moderate to substantial for the QI (0.60-0.66), moderate for the OAA (0.56), and fair to moderate for the QE (0.37-0.47). Interobserver scores were lower: QI and OAA moderate (0.47-0.52, 0.41, respectively) and slight to fair for the QE (0.20-0.24). QI scores for the entire and distal small bowel were highly correlated for each reader (0.57-0.87), and distal small-bowel scores were lower by 1.3 points, indicating poorer cleansing (P = .001). A dichotomized QE of excellent/good versus fair/poor had moderate to substantial intraobserver and interobserver reliability (0.58-0.66, 0.41-0.49, respectively). There was a strong and highly significant association among all 3 scales (P < .001 between QI and both QE and OAA).

CONCLUSION

We have described and validated 3 scales for grading small-bowel cleansing for CE. An evaluation of small-bowel cleansing should be routinely incorporated into the CE report.

Management of obscure occult gastrointestinal bleeding: a cost-minimization analysis

BACKGROUND & AIMS

Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) allow complete small-bowel examination but consume additional health care resources. A cost-minimization analysis determined the optimal initial management strategy for obscure occult gastrointestinal bleeding (OGIB).

METHODS

We compared 5 strategies: initial small-bowel follow-through, enteroclysis, push enteroscopy (PE), CE, or DBE. Incorporation of multiple tests was allowed with costs taken from a third-party payer perspective. We modeled medically refractory disease with 2 separate model end points in which treatment or definitive diagnosis was necessary and in which visual diagnosis was sufficient to suspend testing. Sensitivity analyses included variations in parameter estimates, Monte Carlo simulation, and structural variations in the model in which DBE was not available as an initial strategy.

RESULTS

When treatment or definitive diagnosis was necessary, the optimal strategy was initial DBE at a cost of $3824. An initial CE strategy costs an incremental $440. CE was preferred when DBE exceeded $1849 or when the sensitivity of DBE decreased to less than 68%. If DBE was unavailable as an initial test then CE was preferred to PE unless CE exceeded $1190, capsule retention was greater than 3%, or 64% of lesions were within reach of PE. When visual diagnosis was sufficient, initial CE was preferred.

CONCLUSIONS

For OGIB, initial DBE may be the least expensive strategy when treatment or definitive diagnosis is necessary and initial CE may be preferred when visual identification is sufficient. In settings where DBE is not available as an initial test, initial CE may be the preferred strategy.

Vascular lesions of the gastrointestinal tract

Classification of vascular abnormalities of the gastrointestinal tract on the basis of anatomy and pathophysiology has recently been suggested. Angiodysplasia, an example of an arteriovenous lesion, may cause either acute or chronic bleeding. Diagnosis may be difficult. High-quality standard endoscopy, capsule endoscopy, and double-balloon enteroscopy are most efficacious. Therapy using argon plasma coagulation is currently preferred. Pharmacological therapy has been employed, but a final conclusion about its efficacy cannot yet be drawn. Dieulafoy lesion, an arterial type of vascular abnormality, is rare but serious. It can be responsible for severe haemorrhage. Mechanical endoscopic methods are the most efficacious. Gastric antral vascular ectasia (GAVE), a capillary lesion, can be safely biopsied; it coincides with several diseases (including liver cirrhosis), may cause chronic iron-deficiency anaemia, and is best treated by argon plasma coagulation. Haemangiomas, benign neoplastic lesions, usually occur as part of other specific syndromes; they are difficult to manage due to the multiplicity and size of the lesions.

Efficiency of bowel preparation for capsule endoscopy examination: A meta-analysis

Good preparation before endoscopic procedures is essential for successful visualization. The small bowel is difficult to evaluate because of its length and complex configuration. A meta-analysis was conducted of studies comparing small bowel visualization by capsule endoscopy with and without preparation. Medical data bases were searched for all studies investigating the preparation for capsule endoscopy of the small bowel up to July 31, 2007. Studies that scored bowel cleanness and measured gastric and small bowel transit time and rate of cecum visualization were included. The primary endpoint was the quality of bowel visualization. The secondary endpoints were transit times and proportion of examinations that demonstrated the cecum, with and without preparation. Meta-analysis was performed with StatDirect Statistical software, version 2.6.1 (http://statsdirect.com). Eight studies met the inclusion criteria. Bowel visualization was scored as “good” in 78% of the examinations performed with preparation and 49% performed without (P < 0.0001). There were no significant differences in transit times or in the proportion of examinations that demonstrated the cecum with and without preparation. Capsule endoscopy preparation improves the quality of small bowel visualization, but has no effect on transit times, or demonstration of the cecum.

Evaluation of capsule endoscopy in active, mild-to-moderate, overt, obscure GI bleeding

BACKGROUND

The role of capsule endoscopy (CE) in the diagnosis of active mild-to-moderate GI bleeding (GIB) immediately after a negative EGD and ileocolonoscopy has not been prospectively evaluated.

OBJECTIVE

To estimate the diagnostic yield and clinical significance of CE in patients with acute, obscure, overt, mild-to-moderate GIB.

DESIGN

A single-center prospective study.

PATIENTS

During a 3-year period, 573 patients admitted to the hospital with acute mild-to-moderate GIB were included in this study. Among them, 37 patients (6.5%) with negative endoscopic findings, after urgent upper- and lower-GI endoscopies, underwent CE within the first 48 hours to identify the source of bleeding.

RESULTS

CE revealed active bleeding in 34 patients and a diagnostic yield of 91.9%, including angiodysplasias in 18 patients, ulcers in 3 patients, and tumors in 2 patients. In the remaining 11 patients (32%), CE revealed the site of bleeding: distal duodenum in 1 case (9%), jejunum in 6 cases (54%), ileum in 2 cases (18%), and cecum in 2 cases (18%). From the 37 bleeders, 16 were managed conservatively, 14 endoscopically, and 7 surgically. During a 12-month follow-up period, bleeding recurrence was observed in 5 of 32 (15.6%).

LIMITATIONS

This study had a limited number of patients.

CONCLUSIONS

CE appeared to have a high diagnostic yield in patients with acute, mild-to-moderate, active hemorrhage of obscure origin when performed in the hospital after a negative standard endoscopic evaluation and has important clinical value in guiding medical management.

Impact of therapeutic interventions induced by capsule endoscopy on long term outcome in chronic obscure GI bleeding

BACKGROUND

The diagnostic yield and the clinical impact of capsule endoscopy (CE) in obscure gastrointestinal bleeding (OGIB) are well known. The aim of this study was to determine the impact of therapeutic interventions induced by CE findings on long term outcome.

PATIENTS AND METHODS

Patients with chronic OGIB referred to our center from September 2003 to June 2005 for CE were included. Treatment of intestinal lesions was prescribed according to the clinical characteristics of patients and the nature of the lesions.

RESULTS

Forty patients were included, 18 females and 22 males. Median age was 54 yrs (range: 5-87) with a median follow-up of 13 months (range: 6-22). The diagnostic yield of CE was 75% (30/40). From 30 patients with positive CE, 16 received treatment (Group I) and 14 did not (Group II). Thus clinical impact was 40%. Ten patients had negative CE (Group III). During follow-up, bleeding recurrence was observed in only 1 patient from Group I (6%), 5 from Group II (36%) and 1 from Group III (10%). There were only significant differences between Group I vs Group II (P=0.002).

CONCLUSIONS

CE results had a favorable influence in patient outcome allowing for specific treatment as they showed significantly reduced recurrent bleeding.

Etiology and diagnosis of small intestinal bleeding

The etiology of intestinal bleeding is complicated and its diagnosis is relatively difficult because clinical symptoms and signs commonly obscure alimentary tract bleeding. Present diagnostic methods include enteroscopy, barium and air double contrast X-ray examination, selective angiography, nuclear scintigraphy, and helical computed tomography. Application of double-balloon enteroscopy and wireless capsule endoscopy offers new methods for the diagnosis of small intestinal bleeding. Such patients sometimes still need to undergo laparoscopy or exploration laparotomy even when advanced investigation methods are used. This paper reviews the etiology of small intestinal bleeding and evaluates the advantages and disadvantages of different diagnostic methods to provide clinicians with a reference for etiological analysis and clinical determination of small intestinal bleeding.

Utility of capsule endoscopy for the classification of Crohn's disease: a multicenter study in Korea

Capsule endoscopy can detect lesions associated with Crohn's disease in the small bowel that go unrecognized by conventional radiologic imaging. The aim of this study was to assess the value of capsule endoscopy in the classification of patients with Crohn's disease. This study was carried out on 52 patients with known Crohn's disease. Small bowel follow-through findings were compared with capsule endoscopic findings. All patients were classified according to the extent of the disease: small bowel-colon type, small bowel type, or colon type. Seventeen patients who were reported as being normal showed evidence of small bowel Crohn's disease according to capsule endoscopy. Differences were observed between the small bowel follow-through and the capsule endoscopy classification (kappa=0.54). Treatment was changed based on the results of wireless capsule endoscopy in 15 patients.

The role of wireless capsule endoscopy in the evaluation of patients with suspected small bowel bleeding: A single center experience

Background: Capsule endoscopy (CE) is a new diagnostic tool for the study of patients with suspected small bowel pathology. The aim of the study was to clarify the usefulness of CE in the group of patients with obscure (overt / occult) gastrointestinal (GI) bleeding. Patients and methods: Thirty patients (14 men, 16 women, mean age 50 years, range 9 -79 years) were enrolled in the study. All of them undergone non-diagnostic esophagogastroduodenoscopy, colonoscopy and barium follow-through of the small bowel. All patients underwent capsule endoscopy. Fourteen patients had overt and sixteen occult bleeding. The single senior endoscopist interpreted CE findings in an unblended manner. Results: CE identified a source of bleeding in 14/30 patients (46,6 %). Lesions identified were: tumors in five pts, vascular lesions, Crohn's disease and Meckel's diverticulum in two pts and fresh bleeding, segmental celiac disease and colonic diverticulosis in one patient each. CE identified a source of bleeding in 9/14 (64,3%) of patients with ongoing overt bleeding and in only 5/16 (31,3%) of patients with occult bleeding. The positive suspicious findings were seen in 6/30 (20%) of patients (2/14 with overt bleeding and 4/16 with occult bleeding. In 3/14 (21,4%) with overt and 7/16 (43,7%) with occult bleeding findings on CE were negative. All patients with negative findings on follow-up remained asymptomatic for one year. Capsule retention because of unsuspected stenosis occurred in a single patient and required surgery, which resolved the problem. Conclusion: CE is an effective diagnostic tool for patients with obscure GI bleeding. It is safe and painless technique which can diagnose the bleeding site beyond the reach of conventional endoscopy. The best candidates for the procedure are those with ongoing and overt bleeding.

Abdominal pain accompanied by weight loss may increase the diagnostic yield of capsule endoscopy: a Korean multicenter study

OBJECTIVE

Capsule endoscopy (CE) is approved for the evaluation of obscure gastrointestinal (GI) bleeding and its use has increased in the assessment of patients with various small-bowel disorders. The yield of CE for indications of disorders other than GI bleeding is not yet well described. The aim of the present study was to determine in which subgroup of patients with unexplained abdominal pain, CE would be a helpful evaluation tool.

MATERIAL AND METHODS

The results of CE in 110 patients (70 M, 40 F, mean age 50.8+/-14.1 years) with unexplained abdominal pain from 12 tertiary referral centers between September 2002 and September 2004 were retrospectively analyzed.

RESULTS

The visualization of the small bowel to the cecum was successfully carried out in 69.1% of the patients. Nineteen out of the 110 cases revealed positive findings that explained the symptoms of the patient (diagnostic yield=17.3%). Diagnosis included small-bowel stricture (5), Crohn's disease (3), small-bowel tumor (2), radiation-induced enteritis (1), NSAID-induced enteropathy (1), ischemic ileitis (1), diffuse lymphangiectasia (1), and significant erosion or ulceration (5). By univariate logistic regression analysis, the positive findings of CE were significantly associated with weight loss (odds ratio (OR), 11.9; 95% CI [2.0, 70.6]), elevated erythrocyte sedimentation rate (ESR) (>20 mm/h) (OR, 11.5; 95% CI (1.9, 69.5)), elevated C-reactive protein (CRP) (>or=0.4 mg/dL) (OR, 5.0; 95% CI (1.6, 15.9)), and hypoalbuminemia (albumin<3 g/dL) (OR, 23.1; 95% CI (2.4, 223.1)). Using a multivariate analysis, weight loss was found to be a significant risk factor for positive findings of CE (OR, 18.6; 95% CI (1.6, 222.4), p=0.02).

CONCLUSIONS

The results of this study suggest that CE can be helpful in patients suffering from abdominal pain that cannot be explained by established examinations, if the pain is accompanied by weight loss.

How much helpful is the capsule endoscopy for the diagnosis of small bowel lesions?

AIM: To assess the practically usefulness and diagnostic yield of this new method in a group of patients with suspected small bowel lesions.

METHODS: Capsule endoscopic (CE) examination by using M2A capsule endoscope TM (Given Imaging, Yoqneam, Israel) was performed in thirty nine patients (26 males, 13 females) with suspected small intestinal lesions. The composing of the patients was as follows: obscure gastrointestinal bleeding in twenty three patients, known Crohn’s disease in 6 patients, in whom CE was used to evaluate the severity and extension of the diseases, chronic diarrhea in 8 patients, abdominal pain in one patient and malignancy in one patient with unknown origin.

RESULTS: In two patients CE failed. Different abnormalities were revealed in 26 patients overall. Detection rate of abnormalities was highest among patients with obscure gastrointestinal bleeding and the source of bleeding was demonstrated in 17 of 23 patients with obscure bleeding (73.9%). Entero-Behcet was diagnosed in two patients by CE as a source of obscure gastrointestinal bleeding. In 6 patients with known Crohn's disease, CE revealed better evaluation of the disease extension. In 3 of 8 (37.5%) patients with chronic diarrhea; CE revealed some mucosal abnormalities as the cause of chronic diarrhea. In a patient with unexplained abdominal pain and in a cancer patient with unknown origin, CE examination was normal.

CONCLUSION: In our relatively small series, we found that capsule endoscopy is a useful diagnostic tool particularly in diagnosis of obscure gastrointestinal bleeding, chronic diarrhea and in estimating the extension of Crohn’s disease.

Bleeding update

Obscure bleeding is a consolidated indication to CE, which when used as a first-line exploration is the most efficient strategy as regards diagnosis in these patients. Patient selection and timing of the procedure are of paramount importance in the high diagnostic yield of CE. When integrated into a global patient care plan, CE is helpful in achieving effective decision-making concerning subsequent investigations and treatments. Although most studies appear to indicate a positive influence of CE diagnosis on clinical outcome of OGIB patients, large prospective trials are warranted to assess what is the most effective therapeutic strategy in patients with vascular lesions.

Diagnosis of small-bowel diseases in the era of capsule endoscopy

Capsule endoscopy is a major breakthrough in gastrointestinal endoscopy and is a first-line tool to detect abnormalities of the small bowel, in up to 50% of patients, intestinal disorders are not associated with any physical findings or positive tests. Indications, yield and impact on patient management of this method of diagnosing small-bowel diseases are analyzed critically in light of current scientific knowledge.

Capsule endoscopy - comparison of two strategies of bowel preparation

BACKGROUND

Capsule endoscopy can identify lesions of the small bowel that cannot be detected by other techniques. In addition to patient safety, quality of care and cost-efficiency, good preparation is an important factor for good visualization.

AIM

To evaluate the efficacy of oral sodium phosphate preparation.

METHODS

Forty-six consecutive patients scheduled for capsule endoscopy in two medical centres. The patients treated in Dallas were prepared by 12 h fasting (group A), and those treated in Israel were also asked to drink 45 mL of sodium phosphate with water (group B). An experienced endoscopist, blinded to the method used, graded the quality of preparation according to visual capability, and to relative durations of each grade.

RESULTS

The quality of the preparation was poor in 35% of group A compared with 4% of group B (P = 0.023). The mean duration of good preparation with excellent visualization was 122 +/- 110 min in group A and 180 +/- 96 min in group B (P = 0.006). Preparation with sodium phosphate and lower patient weight were significant predictive factors for good visualization.

CONCLUSIONS

Bowel preparation offers better visualization than overnight fasting alone and is associated with fewer disturbances by intraluminal turbid fluid.

Laparoscopy-Assisted Exploration of Obscure Gastrointestinal Bleeding After Capsule Endoscopy: The Korean Experience

BACKGROUND

Obscure gastrointestinal bleeding (OGB) is generally defined as recurrent acute or chronic bleeding for which no source has been identified by routine radiologic and endoscopic examination. The aim of this study was to report our early experiences detecting small bowel bleeding by capsule endoscopy (CE) and the results of laparoscopy assisted surgery for OGB.

MATERIALS AND METHODS

Seventy-five patients with OGB were examined by CE. Twelve of 24 patients in the active bleeding group underwent laparoscopic or laparoscopy assisted surgery and we carried out intraoperative enteroscopy to find the focus of the bleeding.

RESULTS

Laparoscopic localization of the lesion was successful for 4 patients-those with Meckel's diverticulum, gastrointestinal stromal tumor, lymphoma, and ischemic necrosis. In 3 cases in which there was no natural passage of the capsule endoscope, lesions were identified by small bowel exploration through simple palpation by hand. Intraoperative enteroscopy was performed extracorporeally in 5 cases through a minilaparotomy window using an extended incision of a port site less than 7 cm in length. The lesions that were identified by CE preoperatively were resected successfully, via laparoscopic or laparoscopy-assisted surgery. The gastrointestinal bleeding has not recurred during the postoperative follow-up period (mean, 10.6 months).

CONCLUSION

The laparoscopic approach can be chosen for surgical management of OGB patients with active bleeding whose lesions have been identified by CE. This approach allows minimally invasive surgical treatment for ongoing OGB.

From Colonic Polyps to Colon Cancer: Pathophysiology, Clinical Presentation, and Diagnosis

Epidemiologists, basic researchers, clinicians, and public health administrators unite! Develop and implement a simple, safe, and effective preventive and screening test for colon cancer. The public will willingly and enthusiastically accept such a test. Many thousands of lives are at stake every year.

Video capsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus omeprazole, and placebo

BACKGROUND & AIMS

Data indicate that cyclooxygenase-2-specific inhibitors cause less gastroduodenal mucosal damage than nonspecific NSAIDS, but their effects on the small bowel mucosa are less well recognized. In a multicenter, double-blind, placebo-controlled trial with video capsule endoscopy (VCE) we prospectively evaluated the incidence of small bowel injury in healthy subjects treated with celecoxib compared to naproxen plus omeprazole.

METHODS

We randomly assigned subjects with normal baseline VCEs to celecoxib 200 mg twice daily (n = 120), naproxen 500 mg twice daily plus omeprazole 20 mg once daily (n = 118), or placebo (n = 118) for 2 weeks. The primary end point was the mean number of small bowel mucosal breaks per subject.

RESULTS

Baseline VCE found small bowel lesions in 13.8% (57/413) of screened subjects, who became ineligible for randomization. The mean number of small bowel mucosal breaks per subject and the percentage of subjects with these mucosal breaks were 2.99 +/- 0.51, 55% for naproxen/omeprazole compared to 0.32 +/- 0.10, 16% for celecoxib and 0.11 +/- 0.04, 7% for placebo (P < .001, both comparisons). The magnitude of the difference between celecoxib and placebo was small but statistically significant (P = .04).

CONCLUSIONS

Among healthy subjects with lesion-free baseline VCEs, celecoxib was associated with significantly fewer small bowel mucosal breaks than naproxen plus omeprazole. This study also showed that the background incidence of small bowel lesions in healthy adults is not insignificant and should be considered in future trials with VCE.

Small Bowel Bleeding

The management of patients with small bowel bleeding remains a diagnostic and therapeutic challenge. In most gastrointestinal bleeding episodes, the source of hemorrhage is localized to either the upper gastrointestinal tract or colon; however, in about 5% of cases, upper endoscopy and colonoscopy are nondiagnostic, and the small intestine is the site of bleeding. Patients with suspected small bowel source of bleeding may present with either occult blood loss or recurrent overt gastrointestinal hemorrhage requiring frequent blood transfusions and hospitalizations. Knowing the etiology and site of hemorrhage is essential prior to initiating appropriate therapy. The most common causes of small bowel bleeding are vascular ectasia, tumors, ulcerative diseases, and Meckel's diverticula. For patients with severe obscure bleeding, push enteroscopy with a 220- to 250-cm enteroscope is strongly recommended. This procedure provides not only a thorough examination for diagnosis, but also allows for biopsy, tattooing, and hemostasis of lesions. If enteroscopy is nondiagnostic, capsule endoscopy is recommended. A diagnostic capsule endoscopy will direct appropriate medical, endoscopic, or surgical intervention, depending on whether the lesion is single or multiple, and whether the patient is a surgical candidate for intraoperative enteroscopy. Intraoperative enteroscopy should be strongly considered in patients with recurrent bleeding and a nondiagnostic evaluation. Laparoscopy and intraoperative enteroscopy is highly recommended in young patients (< 50 years of age) because there is an increased frequency of small bowel tumors and Meckel's diverticulum which are amenable to surgical therapy.

The development and application of wireless capsule endoscopy

The introduction of the Video Capsule Endoscope (VCE) by Given Imaging Ltd. (Yoqneam, Israel) in 2001, and its subsequent approval by the FDA as a first line tool in the detection of abnormalities of the small bowel, is indicative of the rapid acceptance of capsule endoscopy by the practicing gastroenterological community. An extensive clinical trials program consistently revealed a high diagnostic yield of the VCE when compared to other diagnostic modalities of the small intestine. The capsule endoscope contains a miniature color video camera, illumination sources, lens, transmitter/controller, antenna, and a power source. It is small enough to easily swallow (11 x 26 mm), and it is propelled through the gastrointestinal (GI) tract by peristalsis. Its development was enabled by a series of technological breakthroughs that occurred at the close of the 20th century. The VCE is one of the most exciting examples of the recent trend for minimally invasive autonomous medical tools in diagnostic, monitoring, and therapeutic applications. Expanding applications of the VCE to additional parts of the GI tract, adding physiological sensors, and--in the more remote future--addition of therapeutic capabilities will likely occur as this new branch of endoscopy develops.

The pathophysiology, clinical presentation, and diagnosis of colon cancer and adenomatous polyps

A review of the pathophysiology, clinical presentation, and diagnosis of colon cancer and colonic polyps is important and timely. This field is rapidly changing because of breakthroughs in the molecular basis of carcinogenesis and in the technology for colon cancer detection and treatment. This article reviews colon cancer and colonic polyps, with a focus on recent dramatic advances, to help the pri-mary care physician and internist appropriately refer patients for screening colonoscopy and intelligently evaluate colonoscopic findings to reduce the mortality from this cancer.

Second capsule endoscopy for patients with severe iron deficiency anemia

BACKGROUND

Patients with iron deficiency anemia are subjected to multiple endoscopic and radiologic examinations of the GI tract. If negative, some of the examinations are repeated, occasionally with positive findings. The diagnostic yield of a second capsule endoscopy in such patients is unknown. The aim of the current study was to assess the diagnostic yield of a second capsule endoscopy in patients with significant iron deficiency anemia and a previous negative evaluation.

METHODS

Twenty patients with iron deficiency anemia (Hb < 10 g/dL) were enrolled. All had at least one normal evaluation of the GI tract, including capsule endoscopy. A second capsule endoscopy examination was offered to all patients.

RESULTS

The time between the first and the second capsule endoscopy ranged from 2 months to 1 year. Depending on the nature of an abnormality and its relevance to blood loss, the findings were classified as positive, suspicious, clinically irrelevant, or negative. In 7 patients, the second capsule endoscopy disclosed findings that were classified as either positive or suspicious findings, including arteriovenous malformations (2), flat polypoid lesion (1), edematous inflamed mucosa (1), erosions (1), and hemorrhagic gastritis (1). Lesions were located in the small intestine (5), the stomach (1), and the cecum (1). Based on the findings of the second capsule endoscopy, therapy was changed in two patients (10%).

CONCLUSIONS

A second capsule endoscopy should be considered for patients with severe iron deficiency anemia and negative initial evaluation.

Robotic technology in surgery: Past, present, and future

It has been nearly 20 years since the first appearance of robotics in the operating room. In that time, much progress has been made in integrating robotic technologies with surgical instrumentation, as evidenced by the many thousands of successful robot-assisted cases. However, to build on past success and to fully leverage the potential of surgical robotics in the future, it is essential to maximize a shared understanding and communication among surgeons, engineers, entrepreneurs, and healthcare administrators. This article provides an introduction to medical robotic technologies, develops a possible taxonomy, reviews the evolution of a surgical robot, and discusses future prospects for innovation. Robotic surgery has demonstrated some clear benefits. It remains to be seen where these benefits will outweigh the associated costs over the long term. In the future, surgical robots should be smaller, less expensive, easier to operate, and should seamlessly integrate emerging technologies from a number of different fields. Such advances will enable continued progress in surgical instrumentation and, ultimately, surgical care.

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Capsule endoscopy in real life: a four-centre experience of 160 consecutive patients in Israel

OBJECTIVE

The Given Capsule procedure is a new system designed to aid the gastroenterologist in diagnosing small-bowel disease. Capsule endoscopy has provided gastroenterologists with easy access to small-bowel mucosa for examination by direct visualisation. The aim of our prospective study was to determine the indication for capsule endoscopy and to describe the identified pathology within the gastrointestinal tract.

METHODS

Patients with unexplained gastrointestinal bleeding from suspected small-bowel pathology of an undisclosed nature or with unexplained abdominal pain for more than 6 months were eligible to undergo capsule endoscopy. Patients with suspected intestinal obstruction or with a history of major abdominal surgery were excluded.

RESULTS

One hundred and sixty patients (70 women, 90 men; mean age 49.0 +/- 19.8 years, range 13-91 years) ingested the capsule easily. They had undergone 6 +/- 2.9 investigative procedures before capsule endoscopy. Two (1.25%) patients who had non-natural excretions underwent surgery: one was found to have Meckel's diverticulum and the other had stricturing Crohn's disease. The mean haemoglobin in iron-deficiency anaemia patients was 9.1 +/- 2.2 g%. The diagnostic yield of capsule endoscopy was 57.7% in iron-deficiency anaemia and 52.4% in suspected Crohn's disease.

CONCLUSIONS

Capsule endoscopy detected the more clinically significant intestinal lesions. It was of diagnostic value in patients with obscure bleeding, suspected Crohn's disease and malabsorption, but the diagnostic yield in patients with chronic pain or irritable bowel syndrome-type symptoms was low.

The role of video capsule endoscopy in the evaluation of iron deficiency anaemia

It is widely accepted that chronic occult blood loss from the gastrointestinal tract is a major cause of iron deficiency anaemia. Endoscopists are often asked to evaluate iron deficiency anaemia and identify the source of bleeding. This review offers an effective diagnostic strategy for this common clinical problem. After investigating the normal upper and lower parts of the gastrointestinal tract, the source of bleeding remains unidentified in about 10% of patients. The existing guidelines for evaluation of iron deficiency anaemia in patients above the age of 45, who have undergone standard upper and lower gastrointestinal examinations, are limited to a "treat and observe" phase. Small bowel X-ray series fail to detect many mucosal lesions, particularly vascular ectasias. While enteroscopy offers direct visual inspection of the small bowel mucosa beyond the reach of the standard upper endoscopes, this instrument reaches only 80-120 cm beyond the ligament of Treitz and its sensitivity in identifying the source of bleeding varies (24-75% of patients). A new and conceptually simple approach to examining the entire small intestine is video capsule endoscopy of the small bowel. This review addresses the optimal role of video capsule endoscopy in iron deficiency anaemia patients and offers guidelines for the appropriate gastrointestinal evaluation in such patients.