Capsule endoscopy findings in celiac disease associated enteropathy-type intestinal T-cell lymphoma

Patients with enteropathy-associated T-cell lymphoma in the United States from 2000 to 2018: SEER data-base analysis

BACKGROUND

Enteropathy-Associated T-Cell Lymphoma (EATL) is a rare lymphoma of T-cell origin associated with celiac disease. There is limited evidence in the literature about the incidence and causes of death in patients with EATL.

METHODS

We performed a retrospective study through analyzing the Surveillance, Epidemiology, and End Results (SEER) data base to determine the incidence, trends and causes of death of patients with EATL in the U.S from 2000 to 2018. Baseline characteristics with treatment options (surgery, radiotherapy, and chemotherapy), status of patients either alive, dead due to cancer itself or other non-cancerous causes with listing of those non-cancerous causes was retrieved. Sub-group analysis based on sex was also done. Multiple latency periods (<2 year, 2-5, 6-10, 11-15, and more than 15 years) were analyzed following EATL diagnosis.

RESULTS

There were 259 EATL patients, majority were aged 70-74 years old (n = 36, 13.9%), predominantly males 155 (59.8%), most common in whites, (76.4%, n = 198), EATL was the only primary tumor in 177 (68.3%) cases, most common site was small bowel at different sites 84 (32.4%) followed by jejunum specifically 57 (22%), majority went for surgical resection (69.9%, n = 181) followed by chemotherapy (47.5%, n = 123), 217 (83.7%) died during follow-up in this study, CONCLUSION: EATL is a rare entity, mostly seen in males, between 70 and 74 years, and mostly originated in the small bowel. With over 80% death in five-year follow up period, EATL patients showed better survival if they underwent chemotherapy. More studies are needed for further understanding of this rare entity.

Hematemesis as an Initial Presentation of Enteropathy-Associated T-Cell Lymphoma

Enteropathy-associated T-cell lymphoma (EATL) is a tumor of intraepithelial T-lymphocytes arising in the small intestine. Based on the genetic profile, immunohistochemistry, and histology, EATL is divided into two subtypes. EATL type I occurs in individuals with celiac disease (CD) while EATL type II is a sporadic form that occurs in individuals without CD. Intensive chemotherapy and surgery are the mainstay treatment. However, despite the currently available treatment options, the five-year survival rate is only 9%. EATL presents as abdominal pain, nausea, or slow gastrointestinal bleeding. Severe bleeding leading to hemodynamic instability is rarely known in EATL. Therefore, we present a unique case of EATL who presented with acute and severe gastrointestinal bleeding with no prior history of CD.

Endoscopic features and clinical outcomes of enteropathy-associated T-cell lymphoma: A tertiary center retrospective study

METHODS

In this retrospective study, we investigated the endoscopic and clinical features of patients with EATLs at a tertiary center, from January 2008 to October 2020.

RESULTS

From a total of 248 patients with primary intestinal lymphoma, only 11 patients were finally diagnosed with EATLs, all of which were EATL type II. Men were affected twice as commonly as women. The median patient age was 47 years. The most common initial symptom was diarrhea (63.6%). Five patients (45.4%) were at late stage (IV) at diagnosis. The endoscopic appearances were classified into four distinct types: ulcerative type (54.5%), epithelial mass type (18.2%), diffuse infiltration type (9.1%), and nodular type (18.2%). The small bowel was the most common site of involvement (72.7%). The initial endoscopic impression of lymphoma was made in only 3 patients (27.3%). Only 4 patients (36.4%) were histologically confirmed as having EATLs based on the initial biopsy specimen. Five patients (45.5%) received emergency surgery. The median overall survival (OS) was 8 months. The use of chemotherapy and the absence of emergency surgery were associated with a significantly better median OS (P < 0.05).

CONCLUSIONS

EATL may show various endoscopic appearances, and its prognosis is poor. Endoscopists should obtain more knowledge of EATL in order to make an early diagnosis.

Early colon cancer with enteropathy-associated T-cell lymphoma involving the whole gastrointestinal tract: A case report

BACKGROUND

Enteropathy-associated T-cell lymphoma (EATL) is a rare invasive lymphoma derived from gastrointestinal epithelial T lymphocytes. EATL involving the whole gastrointestinal tract accompanied with early colon cancer is extremely rare.

CASE SUMMARY

We present the case of a 67-year-old man with diarrhea for more than 5 mo whose colonoscopy in another hospital showed multiple colonic polyps, which indicated moderate to severe dysplasia and focal early cancer. Therefore, he was referred to our hospital for further endoscopic treatment. Colonoscopy after admission showed that the mucosa of the terminal ileum and the entire colon were slightly swollen and finely granular. Endoscopic mucosal resection was performed for colonic polyps located in the liver flexure of the colon and descending colon, respectively. Histopathological findings revealed diffuse infiltration of medium-sized lymphoid cells in the colonic mucosa and visible lymphoepithelial lesions. The histopathology of the polyp in the descending colon indicated moderately differentiated adenocarcinoma limited to the mucosa with negative resection margins. Additionally, immunohistochemical analysis showed positive staining for CD7 and CD8. Therefore, we arrived at a diagnosis of EATL with early colon cancer. Subsequently, the patient was transferred to the hematology department for chemotherapy. The patient’s diarrhea was not significantly relieved after receiving chemotherapy, and he ultimately died of severe myelosuppression.

CONCLUSION

EATL should be considered in unexplained chronic diarrhea. EATL progresses rapidly with a poor prognosis, especially when accompanied with early colon cancer.

A comprehensive review on the utility of capsule endoscopy in coeliac disease: From computational analysis to the bedside

Small bowel capsule endoscopy (SBCE) can identify macroscopic changes of coeliac disease and assess the extent of disease in the small bowel beyond the duodenum. SBCE has a good sensitivity for the detection of coeliac disease in comparison to histology owing to several ideal features such as a high magnification. It also plays a useful role in detecting complications in patients with refractory coeliac disease. Several studies have been carried out on transforming images obtained from small bowel capsule endoscopy to enable the automated detection of features related to coeliac disease. This review discusses the current roles played by small bowel capsule endoscopy in coeliac disease. It identifies future potential roles of this technique and describes in great detail the role of computational analysis in the detection of coeliac disease and how it can be adapted to current available technology.

Role of capsule endoscopy in alarm features and non-responsive celiac disease: A European multicenter study

BACKGROUND AND AIM

The role of capsule endoscopy (CE) in established celiac disease (CD) remains unclear. Our objective was to analyze the usefulness of CE in the suspicion of complicated CD.

METHODS

This was a retrospective multicenter study. One hundred and eighty-nine celiac patients (mean age: 46.6 ± 16.6, 30.2% males) who underwent CE for alarm symptoms (n = 86, 45.5%) or non-responsive CD (n = 103, 54.5%) were included. Diagnostic yield (DY), therapeutic impact and safety were analyzed.

RESULTS

Capsule endoscopy was completed in 95.2% of patients (small bowel transit time: 270.5 ± 100.2 min). Global DY was 67.2%, detecting atrophic mucosa (n = 92, 48.7%), ulcerative jejunoileitis (n = 21, 11.1%), intestinal lymphoma (n = 7, 3.7%) and other enteropathies (n = 7, 3.7%, six Crohn's disease cases and one neuroendocrine tumor). The DY of CE was significantly higher in patients presenting with non-responsive disease compared to patients with alarm symptoms (73.8% vs 59.3%, P = 0.035). The new findings of the CE modified management in 59.3% of the cases. There were no major complications.

CONCLUSION

Capsule endoscopy may be a moderately helpful and safe diagnostic tool in the suspicion of complicated CD, modifying the clinical course of these patients.

Refractory celiac disease

Refractory celiac disease (RCD) affects patients who have failed to heal after 6-12 months of a strict gluten-free diet (GFD) and when other causes of symptoms (including malignancy) have been ruled out. It may also occur in patients who previously had responded to a long-term GFD. RCD may be categorized as RCD1 (normal immunophenotype) and RCD2 (aberrant immunophenotype). RCD1 usually responds to a continued GFD, nutritional support, and therapeutic agents such as corticosteroids. In contrast, clinical response in RCD2 is incomplete and prognosis is often poor. RCD (particularly RCD2) is associated with serious complications, such as ulcerative jejunitis and enteropathy-associated T-cell lymphoma (EATL). Strict clinical and laboratory criteria should be used to diagnose RCD and specialized tests for aberrancy and clonality should be interpreted in the context of their sensitivity and specificity. Adequate nutritional support and anti-inflammatory treatment may even allow patients with RCD2 to attain a clinical remission.

Celiac Disease and Double-Balloon Enteroscopy: What Can We Achieve?: The Experience of 2 European Tertiary Referral Centers

BACKGROUND

Indications to double-balloon enteroscopy (DBE) are not standardized in celiac disease (CD).

GOALS

To evaluate the clinical usefulness of DBE in complicated CD.

STUDY

DBE findings in celiac patients with suspected small bowel (SB) complications were retrospectively evaluated in 2 tertiary referral centers (Milan and Sheffield). Demographic data of the studied cohort were compared with a database of 1000 noncomplicated CD patients.

RESULTS

Twenty-four CD cases (12 males, P=0.01 vs. controls) were reviewed. Mean age at CD diagnosis (y±SD) was 37±20 versus 27±18 and at SB evaluation 47±15 versus 38±13 (P<0.01 compared with controls). Indications for DBE were refractory CD (#9), gastrointestinal symptoms (#6), severe iron-deficiency anemia (#6), and long standing poor dietary adherence (#3). Two jejunal adenocarcinomas and an ileal neuroendocrine tumor were detected in presence of iron-deficiency anemia. Three type I and 3 type II refractory CD patients showed jejunal ulcerations; 2 of type II presented small white raised patches. Patchy atrophy was observed in nonadherent patients and in 2 on a gluten-free diet for a short time. Therapy was planned in 33% of patients after DBE. No adverse events were detected at follow-up [21 mo (range, 0 to 60 mo)].

CONCLUSIONS

This is the largest international study on the outcomes of DBE in CD demonstrating its usefulness to exclude/confirm malignant or premalignant conditions, associated with even minor lesions. Studies are needed to understand the clinical relevance of the SB endoscopic features and to optimize DBE indications.

Wireless capsule endoscopy

Over the last decade, WCE has established itself as a valuable test for imaging the small intestine. It is a safe and relatively easy procedure to perform that can provide valuable information in the diagnosis of small-bowel conditions. Its applications still remain limited within the esophagus and colon. Future developments may include improving visualization within the esophagus and developing technologies that may allow manipulation of the capsule within the GI tract and biopsy capabilities.

Safety of capsule endoscopy in the octogenarian as compared with younger patients

BACKGROUND

There has been an increased use of capsule endoscopy for the evaluation of small-intestine pathology in very elderly patients, yet the safety profile of this procedure has not been well-established.

OBJECTIVE

To estimate the adverse event rate of capsule endoscopy in patients aged ≥80 years and to compare this rate with that of capsule endoscopy patients aged <80 years.

DESIGN

Retrospective matched cohort study.

SETTING

Single tertiary-care referral center.

PATIENTS

All 195 patients aged ≥80 years who underwent capsule endoscopy between 2005 and 2011 were included, along with 585 capsule endoscopy patients aged <80 years who were matched by sex in a 1:3 fashion.

INTERVENTION

All patients underwent capsule endoscopy and, in selected cases, double-balloon enteroscopy.

MAIN OUTCOME MEASUREMENTS

Adverse event rate of capsule endoscopy, which was defined as capsule retention or aspiration.

RESULTS

Adverse events occurred at a similar frequency in patients aged ≥80 years compared with those aged <80 years (1.03% vs 0.85%; P = 1.00), resulting in a difference of 0.2% (95% confidence interval, -1.8% to 2.1%). All adverse events were related to capsule retention, with no study patients experiencing aspiration.

LIMITATIONS

This was a single-center, retrospective study.

CONCLUSION

Adverse events resulting from capsule endoscopy occur at a similar rate in patients aged ≥80 years compared with those aged <80 years. Capsule endoscopy can be performed safely in the very elderly patient population.

A case of enteropathy-type T-cell lymphoma diagnosed by small bowel enteroscopy: a perspective on imaging-enhanced endoscopy

Enteropathy-type T-cell lymphoma (ETL) or enteropathy-associated T-cell lymphoma is a very rare malignant intestinal tumor. ETL is usually diagnosed by surgery. Endoscopic findings of ETL are not well known, and there are few reports of findings from endoscopy that has been performed only using white light. Additionally, there are no definite treatment guidelines for ETL. Therefore, we report a case of ETL diagnosed by enteroscopy with imaging-enhanced endoscopy and also review recently developed treatment options.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Capsule endoscopy in celiac disease

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

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

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

Enteropathy-associated T-cell lymphoma: a review on clinical presentation, diagnosis, therapeutic strategies and perspectives

INTRODUCTION

Enteropathy-associated T-cell lymphoma (EATL) is a rare complication of celiac disease (<1% of lymphomas) and has a poor prognosis.

METHODS

International literature review with PubMed search (up to January 2009) of pathophysiological, clinical and therapeutic data.

RESULTS

EATL is found in patients with a mean age of 59 years, often with a complication that signals its diagnosis. Refractory celiac disease (RCD), equivalent to low-grade intraepithelial T-cell lymphoma, could be an intermediary between celiac disease and high-grade invasive T-cell lymphoma. The median survival is 7 months, with no significant difference between stages; the cumulative 5-year survival is less than 20%. The poor prognosis is determined by disease that has often spread before it is diagnosed (50%), multifocal involvement of the small bowel (50%), poor general health status and undernutrition, and recurrence of complications (infections, perforations, gastrointestinal haemorrhages, occlusions), thus delaying the chemotherapy and contributing to frequent chemotherapy resistance. There is currently no effective and consensual treatment: preventive surgery for complications is controversial, and the results of chemotherapy are disappointing. The classic CHOP protocol (combination of doxorubicin-cyclophosphamide-vincristine-prednisone) does not have satisfactory results and survival remains poor, especially in patients with underlying RCD. High-dose chemotherapy with autotransplantion seems to only improve the prognosis in localised forms. Allogeneic bone marrow transplantation was not evaluated. In all, 1/3 of patients, being unfit for treatment, die before 3 months and half of treated patients stop chemotherapy prematurely due to inefficacy, intolerance and/or complications.

CONCLUSION

Improvement of the prognosis requires collaboration in order to compose a national cohort, to evaluate new diagnostic and therapeutic strategies and to define prognostic factors.

Endoscopic findings of enteropathy-type T-cell lymphoma by double-balloon enteroscopy and capsule endoscopy

Enteropathy-type T-cell lymphoma (ETL) is a rare primary intestinal disorder, particularly in Japan, and there have been few reports on the endoscopic findings of the disease. Here we report detailed endoscopic findings of ETL based on double-balloon enteroscopy and capsule endoscopy. Double-balloon enteroscopy and capsule endoscopy may be useful tools for diagnosing and monitoring the effects of therapy in patients with ETL.

Capsule retention: a feared complication of wireless capsule endoscopy

Wireless capsule endoscopy is a simple, non-invasive technique for the visualization of the entire small bowel. It was introduced in clinical praxis in 2001 and has already become the method of choice for the investigation of small-bowel pathology. Capsule retention is a major complication, with an overall incidence of 1-2%, although reported rates vary widely from 0% to 21%, depending on the indication for the examination. This complication can occur at any level of the gastrointestinal tract and in most cases runs asymptomatically. However, symptomatic bowel obstruction requiring surgical or endoscopic removal of the impacted capsule can occur. Rarely, capsule retention can lead to intestinal perforation. Despite several years of experience with wireless capsule endoscopy, there is up to the present no safe means of predicting capsule retention. Radiological studies have a low diagnostic yield and tend to underestimate or overestimate small-bowel strictures. The role of the new generation patency capsule (Agile patency capsule) needs to be further documented. The experts agree that obtaining a careful history is perhaps the best single method to detect the possibility of retention.

Enteropathy associated T-cell lymphoma and its precursor lesions

Enteropathy Associated T-cell Lymphoma (EATL) is an intestinal tumour of intra-epithelial lymphocytes. Based on morphology, immunohistochemistry and genetic profile EATL can be divided into two groups. EATL type I is a large cell lymphoma which is highly associated with Coeliac Disease (CD) and mostly presents with malabsorption, weight loss and CD-related symptoms. EATL type II consists of small to medium-sized cells and presents often with obstruction or perforation of the small bowel. This type of EATL has no known association with CD. When EATL has been diagnosed a thorough diagnostic work-up is needed. This work-up preferably includes video capsule enteroscopy (VCE), double-balloon enteroscopy (DBE), computed tomography (CT) combined with 18F-fluorodeoxyglucose positron emission tomography scan (18F-FDG-PET scan) if possible and magnetic resonance enteroclysis (MRE). Nowadays, most EATL patients are treated with chemotherapy mostly preceded by resection of the tumour and followed by stem cell transplantation. Despite these therapies outcome of EATL remains very poor with a 5-year survival of 8-20%. In order to improve survival prospective multicentre trials, studying new therapies are needed. The combination of chemotherapy, monoclonal antibodies and/or apoptosis inducing small molecules might be a potential treatment for EATL in the (nearby) future.

Double-balloon endoscopy depicts diminutive small bowel lesions in gastrointestinal lymphoma

The aim was to determine the prevalence of small bowel involvement in patients with gastrointestinal (GI) lymphoma by double-balloon endoscopy (DBE). We examined 29 patients with primary GI lymphoma by oral and anal DBEs. Clinicopathologic features related to the prevalence of diminutive small bowel involvement and the clinical outcome were retrospectively investigated. Diminutive small bowel lesions were found in 14 patients. The prevalence of the lesions was not different between patients with primary small bowel lymphoma and those with primary extra-small bowel lymphoma (50% versus 47%, P = 0.6). However, clinical stage was more advanced in patients with the lesions than in those without (P < 0.05). The lesions were more frequently found in T-cell lymphoma (100%) and follicular lymphoma (77%) than in the other types of lymphoma (15%) (P < 0.05). Diminutive small intestinal lesions occur in patients with GI lymphoma, especially in those with follicular lymphoma and T-cell lymphoma. GI lymphomas of these histologic types are candidates for scrutiny by DBE.

Management of Enteropathy-Associated T-Cell Lymphoma: An Algorithmic Approach

Perforation of the small intestine is the most lethal complication following induction chemotherapy for enteropathy-associated T-cell lymphoma (EATL). We report a case of EATL with a near perforated jejunal ulcer, and suggest a novel approach towards its management. Surgical resection followed by aggressive chemotherapy should limit chemotherapy-associated gastrointestinal toxicity, thus allowing patients to receive adequate dose and duration of chemotherapy. The presented case highlights potential benefits of surgical intervention prior to chemotherapy for EATL.

Capsule endoscopy: technique and indications

Since it was introduced in 2000, capsule endoscopy has become the gold standard for endoscopic examination of the small bowel in several clinical situations such as obscure gastrointestinal bleeding, suspicion of Crohn's disease, and surveillance of polyposis syndromes. In this technique a miniaturised endoscope, embedded in a swallowable capsule, is propelled through the gut by peristalsis and reaches the right colon in 5-8h. Images captured by the capsule are recorded on a hard drive in a belt worn by the patient. In addition to the extensive literature currently available on small bowel CE, new capsule devices are currently under evaluation for the examination of the colon with the purpose of screening for colorectal cancer, and of the oesophagus for screening for oesophageal varices and Barrett's oesophagus. These latter indications currently remain under evaluation. This review considers the technical aspects of capsule endoscopy and discusses the indications. Issues of safety and tolerance are also discussed.

Capsule endoscopy in celiac disease

Video capsule endoscopy is an attractive and patient-friendly tool that provides high quality images of the small bowel. Obscure gastrointestinal bleeding is the primary and most evaluated indication to capsule endoscopy; however, indications are expanding and a small number of preliminary reports have been presented concerning the role of video capsule endoscopy in the diagnosis of celiac disease. The purpose of this review is to update the current knowledge and to hypothesize on future perspectives of the use of video capsule endoscopy in patients with celiac disease.

Capsule endoscopy in the evaluation of gastrointestinal disease

PURPOSE OF REVIEW

The small bowel has been a technically difficult area to examine. Indirect modalities such as barium follow-through have the disadvantage of attendant radiation exposure. Capsule endoscopy, a novel wireless method of investigation of the small bowel, has acquired an important role in both adult and paediatric medicine.

RECENT FINDINGS

The clinical utility of capsule endoscopy has rapidly expanded since its approval by the Food & Drug Administration in the USA in 2001. It has developed an established role in adults, in the investigation of obscure gastrointestinal bleeding, small bowel Crohn's disease, complications of coeliac disease and surveillance of polyposis syndromes. Despite a lag in its use in paediatrics, capsule endoscopy offers an accurate and effective means of investigating the small bowel in children. It has opened up new horizons and permitted a noninvasive approach to identifying occult lesions in the small bowel of children when conventional imaging has been unhelpful.

SUMMARY

This review appraises the current literature to define the clinical indications and practical aspects of capsule endoscopy that are of interest to the paediatrician.

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.

The value of double-balloon enteroscopy in patients with refractory celiac disease

OBJECTIVE

Patients with refractory celiac disease can develop enteropathy-associated T-cell lymphoma (EATL) or ulcerative jejunitis. Double-balloon enteroscopy allows examination of the small bowel. We prospectively assessed the value of this technique in patients with refractory celiac disease in a tertiary referral center.

METHODS

Small bowel enteroscopy was performed in a total of 21 consecutive patients for lesions like ulcerations (high risk). Biopsy specimens were taken from such lesions and from examined small bowel at three different levels of scope insertion depth. Tissue specimens were evaluated for the modified Marsh classification and for the presence of EATL.

RESULTS

Twenty-four procedures were successfully performed without complications. EATL was found in five patients (24%, 95% CI 10-45%) as circumferential, discrete, or confluent ulcerations. In three of them, Marsh III was found while in the other two patients with EATL Marsh I was found. Another two patients (9%, 95% CI 2-28%) had ulcerative jejunitis in the absence of EATL and histology was compatible with Marsh III. In the remaining 14 patients (54%, 95% CI 35-73%), no high-risk lesions were found. Double-balloon enteroscopy could exclude the presence of EATL in four patients that was suggested by abdominal computerized tomography.

CONCLUSIONS

Complications of refractory celiac disease like ulcerative jejunitis or EATL could efficiently be detected or excluded by double-balloon enteroscopy. This technique should be reserved for patients with refractory celiac disease or patients with a past history of EATL.

Diagnosis and outcome of small bowel tumors found by capsule endoscopy: a three-center Australian experience

OBJECTIVE

The objective of the study was to examine diagnosis and outcome in a series of patients with small bowel tumors detected by capsule endoscopy (CE) in three Australian centers.

METHODS

Review of prospectively collected data from 416 CEs identified 27 tumors in 26 patients. Clinical parameters, tumor histology, and follow-up are reported.

RESULTS

Twenty-seven tumors were identified in 26 patients (mean age 61 +/- 13.7 yr). Indications for CE were obscure gastrointestinal (GI) bleeding (21), suspected tumor (3), abdominal pain (1), diarrhea (1). Prior radiology found a possible lesion in 8 of 23 (35%). Nine tumors were proven benign: hamartoma (4), cystic lymphangioma (1), primary amyloid (1), lipoma (1). Two lesions were non-neoplastic: heterotopic gastric mucosa and inflammatory fibroid polyp. Seventeen tumors were malignant: five adenocarcinomas, six carcinoids, two melanoma metastases, two gastrointestinal stromal tumors (GIST), one colon carcinoma metastasis, one non-Hodgkin's lymphoma. Tumors were surgically resected in 23 patients. Resection was considered curative in 12 (52%). Mean duration of follow-up was 26 +/- 13.7 months. Of the five patients with primary adenocarcinoma only one remains disease free. Three of the six with carcinoid tumors have had no recurrence up to 51 months postresection. Both patients with GIST are disease free. Anemia resolved after surgery in the patients with melanoma.

CONCLUSIONS

Small bowel tumors are a significant finding at CE and are often missed by other methods of investigation. In many patients, detection of a tumor alters management and improves outcome. Even in malignant lesions, treatment is potentially curative in the absence of metastatic disease.

The economics of PillCam

Evaluation of the economics of PillCam technology is in its infancy. Most studies of the use of the PillCam, both small bowel and esophageal, have focused only on the capsules' diagnostic characteristics. Although the results have compared favorably with other more invasive and sometimes less accurate modalities, the true cost effectiveness of PillCam is not yet fully known. The few cost-effectiveness assessments performed suggest that PillCam compares favorably with traditional diagnostic methods in Crohn's disease and in screening for complications of GERD and for esophageal varices. The data included in these models are quite limited, however. Sensitivity analyses can permit assessment of a wide range of possibilities regarding cost and diagnostic efficacy. Still, these models need to be anchored by robust and reproducible data input. Large-scale studies with long-term follow-up are needed. Capture of both direct and indirect medical costs accrued by using PillCam or other diagnostic tests in these studies will permit more robust economic analyses. As data accrue,they may give clinicians more confidence that PillCam use will realize economic savings and improve patient outcomes.

Capsule endoscopy in celiac disease: diagnosis and management

Celiac disease occurs in about 1% of the population. Although diarrhea is the classical presentation, the diagnosis of celiac disease is frequently not considered as part of the differential diagnosis of a variety of different symptoms. It is,therefore, imperative that physicians who perform capsule endoscopy, and those who review the images, are aware of the variety of mucosa appearances inpatients who have celiac disease. In addition, studies are needed to determine the role of capsule endoscopy in the diagnosis and management of celiac disease.