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Stewart J, Fleishman NR, Staggs VS, Thomson M, Stoecklein N, Lawson CE, Washburn MP, Umar S, Attard TM. Small Intestinal Polyp Burden in Pediatric Peutz-Jeghers Syndrome Assessed through Capsule Endoscopy: A Longitudinal Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1680. [PMID: 37892343 PMCID: PMC10605554 DOI: 10.3390/children10101680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/22/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023]
Abstract
The management of pediatric Peutz-Jeghers Syndrome (PJS) focuses on the prevention of intussusception complicating small intestinal (SI) polyposis. This hinges on the accurate appraisal of the polyp burden to tailor therapeutic interventions. Video Capsule Endoscopy (VCE) is an established tool to study SI polyps in children, but an in-depth characterization of polyp burden in this population is lacking. Methods: We performed a retrospective longitudinal cross-sectional analysis of VCE studies in pediatric PJS patients at our institution (CMKC) from 2010 to 2020. Demographic, clinical, and VCE findings reported by three reviewers in tandem were accrued. Polyp burden variables were modeled as functions of patient and study characteristics using linear mixed models adjusted for clustering. Results: The cohort included 15 patients. The total small bowel polyp count and largest polyp size clustered under 30 polyps and <20 mm in size. Luminal occlusion correlated closely with the estimated polyp size. Polyp distribution favored proximal (77%) over distal (66%) small bowel involvement. The adjusted largest polyp size was greater in males. Double Balloon Enteroscopy was associated with a decreased polyp burden. Conclusions: The polyp burden in pediatric PJS patients favors the proximal third of the small intestine, with relatively small numbers and a polyp size amenable to resection through enteroscopy. Male gender and older age were related to an increased polyp burden.
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Affiliation(s)
- Jeremy Stewart
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center, Children’s Medical Center, Dallas, TX 75235, USA
| | - Nathan R. Fleishman
- Division of Gastroenterology, Levine Children’s Hospital, Charlotte, NC 28203, USA
| | - Vincent S. Staggs
- Biostatistics and Epidemiology Core, Division of Health Services and Outcomes Research, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Mike Thomson
- Department of Paediatric Gastroenterology, Sheffield Children’s Hospital NHS Foundation Trust, Sheffield University, Sheffield S10 2TH, UK
| | - Nicole Stoecklein
- Division of Gastroenterology, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Caitlin E. Lawson
- Division of Genetics, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Michael P. Washburn
- Department of Cancer Biology, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Shahid Umar
- Department of Surgery, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Thomas M. Attard
- Division of Gastroenterology, Children’s Mercy Hospital, Kansas City, MO 64108, USA
- University of Missouri–Kansas City School of Medicine, 2464 Charlotte St, Kansas City, MO 64108, USA
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2
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Yamamoto H, Sakamoto H, Kumagai H, Abe T, Ishiguro S, Uchida K, Kawasaki Y, Saida Y, Sano Y, Takeuchi Y, Tajika M, Nakajima T, Banno K, Funasaka Y, Hori S, Yamaguchi T, Yoshida T, Ishikawa H, Iwama T, Okazaki Y, Saito Y, Matsuura N, Mutoh M, Tomita N, Akiyama T, Yamamoto T, Ishida H, Nakayama Y. Clinical Guidelines for Diagnosis and Management of Peutz-Jeghers Syndrome in Children and Adults. Digestion 2023; 104:335-347. [PMID: 37054692 DOI: 10.1159/000529799] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/14/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Peutz-Jeghers syndrome (PJS) is a rare disease characterized by the presence of hamartomatous polyposis throughout the gastrointestinal tract, except for the esophagus, along with characteristic mucocutaneous pigmentation. It is caused by germline pathogenic variants of the STK11 gene, which exhibit an autosomal dominant mode of inheritance. Some patients with PJS develop gastrointestinal lesions in childhood and require continuous medical care until adulthood and sometimes have serious complications that significantly reduce their quality of life. Hamartomatous polyps in the small bowel may cause bleeding, intestinal obstruction, and intussusception. Novel diagnostic and therapeutic endoscopic procedures such as small-bowel capsule endoscopy and balloon-assisted enteroscopy have been developed in recent years. SUMMARY Under these circumstances, there is growing concern about the management of PJS in Japan, and there are no practice guidelines available. To address this situation, the guideline committee was organized by the Research Group on Rare and Intractable Diseases granted by the Ministry of Health, Labour and Welfare with specialists from multiple academic societies. The present clinical guidelines explain the principles in the diagnosis and management of PJS together with four clinical questions and corresponding recommendations based on a careful review of the evidence and involved incorporating the concept of the Grading of Recommendations Assessment, Development and Evaluation system. KEY MESSAGES Herein, we present the English version of the clinical practice guidelines of PJS to promote seamless implementation of accurate diagnosis and appropriate management of pediatric, adolescent, and adult patients with PJS.
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Affiliation(s)
- Hironori Yamamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hirotsugu Sakamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hideki Kumagai
- Department of Pediatrics, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Takashi Abe
- Department of Gastroenterology, Hanwa Sumiyoshi General Hospital, Osaka, Japan
| | | | - Keiichi Uchida
- Department of Pediatric Surgery, Mie University Hospital, Tsu, Japan
| | - Yuko Kawasaki
- University of Hyogo, College of Nursing, Akashi, Japan
| | - Yoshihisa Saida
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yasushi Sano
- Gastrointestinal Center & Institute of Minimally-invasive Endoscopic Care, Sano Hospital, Kobe, Japan
| | - Yoji Takeuchi
- Division of Hereditary Tumors, Department of Gastrointestinal Oncology, And Department of Genetic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | | | - Takeshi Nakajima
- Department of Clinical Genetic Oncology, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - Kouji Banno
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Funasaka
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Shinichiro Hori
- Department of Cancer Genomic Medicine, NHO Shikoku Cancer Center, Matsuyama, Japan
| | - Tatsuro Yamaguchi
- Department of Clinical Genetics, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Teruhiko Yoshida
- Department of Genetic Medicine and Services, National Cancer Center Hospital, Tokyo, Japan
| | - Hideki Ishikawa
- Department of Molecular-Targeting Prevention, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Ishikawa Gastroenterology Clinic, Osaka, Japan
| | - Takeo Iwama
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Yasushi Okazaki
- Intractable Disease Research Center, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | | | - Michihiro Mutoh
- Department of Molecular-Targeting Prevention, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naohiro Tomita
- Cancer Treatment Center, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Takashi Akiyama
- Department of Pediatric Surgery, Chuden Hospital, Hiroshima, Hiroshima, Japan
| | - Toshiki Yamamoto
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hideyuki Ishida
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Yoshiko Nakayama
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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3
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Iwama I, Nambu R, Nakayama Y. Small bowel endoscopy for children: Collaboration of capsule endoscopy and device-assisted enteroscopy. Dig Endosc 2022. [PMID: 36576231 DOI: 10.1111/den.14511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022]
Abstract
Capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE) have become indispensable techniques for the diagnosis and management of small bowel disease in both adult and pediatric cases. However, relevant differences exist in the indications between these cohorts, with body weight and age having particular relevance in decisions for the latter. Both CE and BAE are designed for adult physique and they were not widely used among children. In addition, the types of small intestinal diseases differ between adults and children, and consequently, the indications also differ between them. This review focuses on the issues relevant to pediatric cases and describes the practical application of endoscopy in clinical practice. In conclusion, although there are age and weight restrictions, both CE and BAE are safe and useful devices for use in children, and their indications for use in children are likely to expand in the future.
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Affiliation(s)
- Itaru Iwama
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Ryusuke Nambu
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshiko Nakayama
- Department of Pediatrics, Shinshu University School of Medicine, Nagano, Japan
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Ionescu A, Glodeanu A, Ionescu M, Zaharie S, Ciurea A, Golli A, Mavritsakis N, Popa D, Vere C. Clinical impact of wireless capsule endoscopy for small bowel investigation (Review). Exp Ther Med 2022; 23:262. [PMID: 35251328 PMCID: PMC8892621 DOI: 10.3892/etm.2022.11188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/12/2021] [Indexed: 11/06/2022] Open
Abstract
Wireless capsule endoscopy is currently considered the gold standard in the investigation of the small bowel. It is both practical for physicians and easily accepted by patients. Prior to its development, two types of imaging investigations of the small bowel were available: radiologic and endoscopic. The first category is less invasive and comfortable for patients; it presents the ensemble of the small bowel, but it may imply radiation exposure. Images are constructed based on signals emitted by various equipment and require special interpretation. Endoscopic techniques provide real-time colored images acquired by miniature cameras from inside the small bowel, require interpretation only from a medical point of view, may allow the possibility to perform biopsies, but the investigation only covers a part of the small bowel and are more difficult to accept by patients. Wireless capsule endoscopy is the current solution that overcomes a part of the previous drawbacks: it covers the entire small bowel, it provides real-time images acquired by cameras, it is painless for patients, and it represents an abundant source of information for physicians. Yet, it lacks motion control and the possibility to perform biopsies or administer drugs. However, significant effort has been oriented in these directions by technical and medical teams, and more advanced capsules will surely be available in the following years.
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Affiliation(s)
- Alin Ionescu
- Department of Medical History, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Adina Glodeanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mihaela Ionescu
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Sorin Zaharie
- Department of Nephrology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ana Ciurea
- Department of Oncology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Andreea Golli
- Department of Public Health Management, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Nikolaos Mavritsakis
- Department of Physical Education and Sport, ‘1 Decembrie 1918’ University, 510009 Alba Iulia, Romania
| | - Didi Popa
- Department of Information and Communication Technology, University of Craiova, 200585 Craiova, Romania
| | - Cristin Vere
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Monahan KJ, Bradshaw N, Dolwani S, Desouza B, Dunlop MG, East JE, Ilyas M, Kaur A, Lalloo F, Latchford A, Rutter MD, Tomlinson I, Thomas HJW, Hill J. Guidelines for the management of hereditary colorectal cancer from the British Society of Gastroenterology (BSG)/Association of Coloproctology of Great Britain and Ireland (ACPGBI)/United Kingdom Cancer Genetics Group (UKCGG). Gut 2020; 69:411-444. [PMID: 31780574 PMCID: PMC7034349 DOI: 10.1136/gutjnl-2019-319915] [Citation(s) in RCA: 221] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/25/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022]
Abstract
Heritable factors account for approximately 35% of colorectal cancer (CRC) risk, and almost 30% of the population in the UK have a family history of CRC. The quantification of an individual's lifetime risk of gastrointestinal cancer may incorporate clinical and molecular data, and depends on accurate phenotypic assessment and genetic diagnosis. In turn this may facilitate targeted risk-reducing interventions, including endoscopic surveillance, preventative surgery and chemoprophylaxis, which provide opportunities for cancer prevention. This guideline is an update from the 2010 British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland (BSG/ACPGBI) guidelines for colorectal screening and surveillance in moderate and high-risk groups; however, this guideline is concerned specifically with people who have increased lifetime risk of CRC due to hereditary factors, including those with Lynch syndrome, polyposis or a family history of CRC. On this occasion we invited the UK Cancer Genetics Group (UKCGG), a subgroup within the British Society of Genetic Medicine (BSGM), as a partner to BSG and ACPGBI in the multidisciplinary guideline development process. We also invited external review through the Delphi process by members of the public as well as the steering committees of the European Hereditary Tumour Group (EHTG) and the European Society of Gastrointestinal Endoscopy (ESGE). A systematic review of 10 189 publications was undertaken to develop 67 evidence and expert opinion-based recommendations for the management of hereditary CRC risk. Ten research recommendations are also prioritised to inform clinical management of people at hereditary CRC risk.
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Affiliation(s)
- Kevin J Monahan
- Family Cancer Clinic, St Mark's Hospital, London, UK
- Faculty of Medicine, Imperial College, London, UK
| | - Nicola Bradshaw
- Clinical Genetics, West of Scotland Genetics Services, Glasgow, Glasgow, UK
| | - Sunil Dolwani
- Gastroenterology, Cardiff and Vale NHS Trust, Cardiff, UK
| | - Bianca Desouza
- Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - James E East
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Mohammad Ilyas
- Faculty of Medicine & Health Sciences, Nottingham University, Nottingham, UK
| | - Asha Kaur
- Head of Policy and Campaigns, Bowel Cancer UK, London, UK
| | - Fiona Lalloo
- Genetic Medicine, Central Manchester University Hospitals Foundation Trust, Manchester, UK
| | | | - Matthew D Rutter
- Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Ian Tomlinson
- Nuffield Department of Clinical Medicine, Wellcome Trust Centre for Human Genetics, Birmingham, UK
- Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Huw J W Thomas
- Family Cancer Clinic, St Mark's Hospital, London, UK
- Faculty of Medicine, Imperial College, London, UK
| | - James Hill
- Genetic Medicine, Central Manchester University Hospitals Foundation Trust, Manchester, UK
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Management of Peutz-Jeghers Syndrome in Children and Adolescents: A Position Paper From the ESPGHAN Polyposis Working Group. J Pediatr Gastroenterol Nutr 2019; 68:442-452. [PMID: 30585892 DOI: 10.1097/mpg.0000000000002248] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Peutz-Jeghers syndrome (PJS) is a well-described inherited syndrome, characterized by the development of gastrointestinal polyps, and characteristic mucocutaneous freckling. Development of small bowel intestinal polyps may lead to intussusception in children may require emergency laparotomy with potential loss of bowel. Gastrointestinal polyps may lead to bleeding and anemia. This European Society for Paediatric Gastroenterology Hepatology and Nutrition position paper provides a guide for diagnosis, assessment, and management of PJS in children and adolescents and guidance on avoiding complications from PJS or from the endoscopic procedures performed on these patients.This is the first position paper regarding PJS published by European Society for Paediatric Gastroenterology Hepatology and Nutrition. Literature from PubMed, Medline, and Embase was reviewed and in the absence of evidence, recommendations reflect the opinion of pediatric and adult experts involved in the care of polyposis syndromes. Because many of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, some of the recommendations are based on expert opinion. This position paper will be helpful in the appropriate management and timing of procedures in children and adolescents with PJS.
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7
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Ko BM. [Small Bowel Tumors and Polyposis: How to Approach and Manage?]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 72:277-280. [PMID: 30642146 DOI: 10.4166/kjg.2018.72.6.277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 11/03/2022]
Abstract
Although small bowel the mainly occupies the most part of the gastrointestinal tract, small intestine tumors are rare, insidious in clinical presentation, and frequently represent a diagnostic and management challenge. Small bowel tumors are generally classified as epithelial, mesenchymal, lymphoproliferative, or metastatic. Familial adenomatous polyposis and Peutz-Jeghers syndrome are the most common inherited intestinal polyposis syndromes. Until the advent of capsule endoscopy (CE) and device-assisted enteroscopy (DAE) coupled with the advances in radiology, physicians had limited diagnostic examination for small bowel examination. CE and new radiologic imaging techniques have made it easier to detect small bowel tumors. DAE allows more diagnosis and deeper reach in small intestine. CT enteroclysis/CT enterography (CTE) provides information about adjacent organs as well as pictures of the intestinal lumen side. Compared to CTE, Magnetic resonance enteroclysis/enterography provides the advantage of soft tissue contrast and multiplane imaging without radiation exposure. Treatment and prognosis are tailored to each histological subtype of tumors.
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Affiliation(s)
- Bong Min Ko
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
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8
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Yeh HY, Su MY, Lin WP, Lai MW, Chao HC, Chen SY, Chiu CT. Double-balloon enteroscopy for pediatric patients: Application and feasibility evaluation in a medical center in northern Taiwan. J Formos Med Assoc 2018; 118:341-346. [PMID: 30268344 DOI: 10.1016/j.jfma.2018.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 04/25/2018] [Accepted: 05/24/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/PURPOSE The diagnostic and therapeutic benefits of double-balloon enteroscopy (DBE) in adults are established, but few data are available on pediatric patients. The aim of this study was to evaluate the clinical efficacy and safety of DBE in pediatric patients in Taiwan. METHODS From April 2005 to September 2015, DBE procedures performed for diagnosis or therapy of small-bowel disease in children less than 18 years of age at Linkou Chang Gung Memorial Hospital, Taiwan were evaluated. The clinical decision to perform DBE via the oral or anal approach was based on the patient's primary clinical presentation. Data on indications, endoscopic findings, treatment outcome, and complications associated with the procedure were collected and reviewed retrospectively. RESULT In total, 20 pediatric patients underwent a total of 29 DBEs due to suspicion of small-bowel disease. Among them, nine patients were evaluated for suspected small-bowel bleeding, six for Peutz-Jeghers syndrome, two for chronic abdominal pain, two for chronic diarrhea, and one for suspected protein-losing enteropathy. After excluding the six Peutz-Jeghers syndrome patients, 9 of the 14 patients (64%) got a positive endoscopic finding and diagnosis in 8 of the 14 patients (57%). DBE resulted in a further therapeutic intervention (endoscopic or surgical) in 50% of the patients (10/20) without serious complications. CONCLUSION DBE has a high diagnostic yield and leads to therapeutic interventions in pediatric patients and shows promise for assessment and treating small-intestinal diseases in children in Taiwan.
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Affiliation(s)
- Hung-Yu Yeh
- Division of Pediatric Gastroenterology, Chang Gung Children's Hospital, Linkou, Taoyuan, Taiwan
| | - Ming-Yao Su
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan, Taiwan
| | - Wei-Pin Lin
- Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan, Taiwan; Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsun-Ching Chao
- Division of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shih-Yen Chen
- Division of Pediatric Gastroenterology, Chang Gung Children's Hospital, Chang Gung University College of Medicine, Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan, Taiwan; Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, Taiwan.
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan, Taiwan.
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9
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Sanchez-Mete L, Stigliano V. Update on small bowel surveillance in hereditary colorectal cancer syndromes. TUMORI JOURNAL 2018; 105:12-21. [PMID: 30117372 DOI: 10.1177/0300891618792461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite its rarity in the general population, small bowel adenocarcinoma risk is increased in individuals with hereditary colorectal cancer syndromes (HCCS). In the last decade, the advent of capsule endoscopy and device-assisted balloon enteroscopy procedures in patients with HCCS have allowed to investigate the whole small bowel, increasing the diagnostic yield of small bowel tumor. Nonetheless, there is a significant variability in the international guideline recommendations. The aim of this review is to provide an update on surveillance of small bowel in HCCS and to identify the key points for the clinical management of these patients.
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Affiliation(s)
- Lupe Sanchez-Mete
- Division of Gastroenterology and Digestive Endoscopy, Regina Elena National Cancer Institute, Rome, Italy
| | - Vittoria Stigliano
- Division of Gastroenterology and Digestive Endoscopy, Regina Elena National Cancer Institute, Rome, Italy
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10
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Yamamoto H, Ogata H, Matsumoto T, Ohmiya N, Ohtsuka K, Watanabe K, Yano T, Matsui T, Higuchi K, Nakamura T, Fujimoto K. Clinical Practice Guideline for Enteroscopy. Dig Endosc 2017; 29:519-546. [PMID: 28370422 DOI: 10.1111/den.12883] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.
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Affiliation(s)
| | - Haruhiko Ogata
- Japan Gastroenterological Endoscopy Society
- Japanese Society of Gastroenterology
| | - Takayuki Matsumoto
- Japan Gastroenterological Endoscopy Society
- Japanese Gastroenterological Association
| | - Naoki Ohmiya
- Japan Gastroenterological Endoscopy Society
- Japanese Association for Capsule Endoscopy
| | - Kazuo Ohtsuka
- Japan Gastroenterological Endoscopy Society
- Japanese Gastroenterological Association
| | - Kenji Watanabe
- Japanese Society of Gastroenterology
- Japanese Association for Capsule Endoscopy
| | - Tomonori Yano
- Japan Gastroenterological Endoscopy Society
- Japanese Association for Capsule Endoscopy
| | - Toshiyuki Matsui
- Japan Gastroenterological Endoscopy Society
- Japanese Gastroenterological Association
| | - Kazuhide Higuchi
- Japan Gastroenterological Endoscopy Society
- Japanese Society of Gastroenterology
| | - Tetsuya Nakamura
- Japan Gastroenterological Endoscopy Society
- Japanese Society of Gastroenterology
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11
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Jelsig AM, Qvist N, Sunde L, Brusgaard K, Hansen T, Wikman FP, Nielsen CB, Nielsen IK, Gerdes AM, Bojesen A, Ousager LB. Disease pattern in Danish patients with Peutz-Jeghers syndrome. Int J Colorectal Dis 2016; 31:997-1004. [PMID: 26979979 DOI: 10.1007/s00384-016-2560-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE In this paper, we aimed to collect genetic and medical information on all Danish patients with Peutz-Jeghers syndrome (PJS), in order to contribute to the knowledge of phenotype and genotype. Peutz-Jeghers syndrome is a hereditary syndrome characterized by multiple hamartomatous polyps in the GI tract, mucocutaneous pigmentations, and an increased risk of cancer in the GI tract and at extraintestinal sites. Over 90 % of patients harbour a pathogenic mutation in STK11. METHODS Based on the Danish Pathology Data Bank, the Danish National Patient Register, as well as information from relevant departments at Danish hospitals, we identified patients and collected clinical and genetic information. RESULTS We identified 43 patients of which 14 were deceased. The prevalence was estimated to be ∼1 in 195,000 individuals. The median age at first symptom was 27.5 with invagination of the small bowel as the most frequent presenting symptom. We noted 18 occurrences of cancer at various anatomical sites, including a case of thyroid cancer and penile cancer. Eight of the deceased patients had died of cancer. Eighteen different mutations in STK11 had been detected in 28 patients. CONCLUSION This is the first comprehensive study of patients with Peutz-Jeghers syndrome in the Danish population identified from nationwide registers and databases. We have demonstrated that the expressivity of Peutz-Jeghers syndrome varies greatly among the patients, even within the same families, underlining the great phenotypic spectrum. Patients with PJS should be offered surveillance from childhood in order to prevent morbidity and reduce mortality.
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Affiliation(s)
- A M Jelsig
- Department of Clinical Genetics, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark. .,Institute of Clinical Research, University of Southern Denmark, Winsløwparken 19, 3, 5000, Odense, Denmark.
| | - N Qvist
- Department of Surgery A, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - L Sunde
- Department of Clinical Genetics, Aarhus University Hospital, Brendstrupgaardsvej 21 C, 8200, Aarhus, Denmark
| | - K Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Winsløwparken 19, 3, 5000, Odense, Denmark
| | - Tvo Hansen
- Center for Genomic Medicine, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - F P Wikman
- Department of Molecular Medicine, Aarhus University Hospital, Brendstrupgaardsvej 21 C, 8200, Aarhus, Denmark
| | - C B Nielsen
- Department of Surgery, Hvidovre Hospital, Kettegårds Alle 30, 2650, Hvidovre, Denmark
| | - I K Nielsen
- Department of Clinical Genetics, Aalborg University Hospital, Ladegaardsgade 5, 9000, Aalborg, Denmark
| | - A M Gerdes
- Department of Clinical Genetics, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - A Bojesen
- Department of Clinical Genetics, Vejle Hospital, Lillebaelt Hospital, Kabbeltoft 25, 7100, Vejle, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Winsløwparken 19, 3, 5000, Odense, Denmark
| | - L B Ousager
- Department of Clinical Genetics, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Winsløwparken 19, 3, 5000, Odense, Denmark
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Urquhart P, Grimpen F, Lim GJ, Pizzey C, Stella DL, Tesar PA, Macrae FA, Appleyard MA, Brown GJ. Capsule endoscopy versus magnetic resonance enterography for the detection of small bowel polyps in Peutz-Jeghers syndrome. Fam Cancer 2015; 13:249-55. [PMID: 24509884 DOI: 10.1007/s10689-014-9700-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Our study aimed to assess the diagnostic utility of magnetic resonance enterography (MRE) compared to capsule endoscopy (CE) for the detection of small bowel polyps in patients with Peutz-Jeghers syndrome (PJS); with findings verified by balloon enteroscopy (BE). Adult patients were prospectively recruited across two tertiary centres and underwent MRE followed by CE, with a subsequent BE performed in patients with significant (≥10 mm) polyps. The primary endpoint was the total number of significant (≥10 mm) small bowel polyps detected. The number of patients with at least one significant polyp, correlation with BE findings, and patients' preferences were secondary endpoints. A total of 20 patients (7 male; mean age 34.9 years) underwent both investigations. The number of polyps ≥10 mm detected by CE was greater than by MRE (47 vs 14 polyps, P = 0.02). The number of patients with at least one significant polyp identified by CE was 11 (55 %) compared with 7 (35 %) identified by MRE (P = 0.25). Subsequent BE in 12 patients identified a total of 26 significant polyps in 8 patients. The positive predictive value of finding a polyp at BE was higher for MRE (100 %) compared to CE (60 %). Overall patient preferences identified CE as the preferred modality. This prospective study demonstrated that CE identifies significantly more small bowel polyps compared with MRE in patients with PJS. Correlation between the two techniques and subsequent BE however was relatively poor.
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Affiliation(s)
- P Urquhart
- The Royal Melbourne Hospital, Parkville, Australia,
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13
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ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes. Am J Gastroenterol 2015; 110:223-62; quiz 263. [PMID: 25645574 PMCID: PMC4695986 DOI: 10.1038/ajg.2014.435] [Citation(s) in RCA: 966] [Impact Index Per Article: 107.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023]
Abstract
This guideline presents recommendations for the management of patients with hereditary gastrointestinal cancer syndromes. The initial assessment is the collection of a family history of cancers and premalignant gastrointestinal conditions and should provide enough information to develop a preliminary determination of the risk of a familial predisposition to cancer. Age at diagnosis and lineage (maternal and/or paternal) should be documented for all diagnoses, especially in first- and second-degree relatives. When indicated, genetic testing for a germline mutation should be done on the most informative candidate(s) identified through the family history evaluation and/or tumor analysis to confirm a diagnosis and allow for predictive testing of at-risk relatives. Genetic testing should be conducted in the context of pre- and post-test genetic counseling to ensure the patient's informed decision making. Patients who meet clinical criteria for a syndrome as well as those with identified pathogenic germline mutations should receive appropriate surveillance measures in order to minimize their overall risk of developing syndrome-specific cancers. This guideline specifically discusses genetic testing and management of Lynch syndrome, familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (AFAP), MUTYH-associated polyposis (MAP), Peutz-Jeghers syndrome, juvenile polyposis syndrome, Cowden syndrome, serrated (hyperplastic) polyposis syndrome, hereditary pancreatic cancer, and hereditary gastric cancer.
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Baltes P, Kurniawan N, Keuchel M. Capsule endoscopy in the evaluation of small bowel tumors and polyps. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2015.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ohmiya N, Nakamura M, Tahara T, Nagasaka M, Nakagawa Y, Shibata T, Hirooka Y, Goto H, Hirata I. Management of small-bowel polyps at double-balloon enteroscopy. ANNALS OF TRANSLATIONAL MEDICINE 2014; 2:30. [PMID: 25333006 DOI: 10.3978/j.issn.2305-5839.2014.02.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 02/13/2014] [Indexed: 12/22/2022]
Abstract
Small bowel tumors (SBTs) are uncommon, insidious in presentation, and frequently represent a diagnostic challenge. The advent of video capsule endoscopy (VCE) and double-balloon endoscopy (DBE) is a significant breakthrough for visual diagnosis of SBTs throughout the small bowel. Contrast-enhanced computed tomography (CECT) and fluoroscopic enteroclysis had significantly lower diagnostic yields of tumors that were 10 mm or smaller in diameter, but VCE and DBE had high diagnostic yields regardless of tumor size. Regarding SBTs larger than 10 mm in diameter, CECT had a significantly lower diagnostic yield of epithelial tumors compared to subepithelial tumors, whereas fluoroscopic enteroclysis and DBE had high diagnostic yields regardless of the tumor type. VCE had a slightly lower diagnostic yield of subepithelial tumors (78%) compared to epithelial tumors. Therefore, a combined examination method by using CECT and VCE is useful for screening of SBTs. In case suspicious of stenosis, patency capsule should be performed to confirm passage before VCE. DBE is useful for further precise examination including biopsy and ultrasonography by using miniature probe, and enteroscopic treatment. After medical, enteroscopic, and surgical treatment, VCE is helpful for follow-up. DBE is safe and useful in resecting the SBTs deep within the small bowel without laparotomy. Indications of enteroscopic resection may be benign tumors regardless of epithelial or subepithelial type, localizing in the mucosal or submucosal layer, which are symptomatic at present or possibly symptomatic or transforming in the future. Malignant tumors localized in the mucosal layer may be indications although detecting at an early stage is challenging. In this review article, we describe management of SBTs/polyps by various modalities.
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Affiliation(s)
- Naoki Ohmiya
- 1 Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan ; 2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan ; 3 Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Masanao Nakamura
- 1 Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan ; 2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan ; 3 Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Tomomitsu Tahara
- 1 Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan ; 2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan ; 3 Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Mitsuo Nagasaka
- 1 Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan ; 2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan ; 3 Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yoshihito Nakagawa
- 1 Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan ; 2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan ; 3 Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Tomoyuki Shibata
- 1 Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan ; 2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan ; 3 Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yoshiki Hirooka
- 1 Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan ; 2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan ; 3 Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Hidemi Goto
- 1 Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan ; 2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan ; 3 Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Ichiro Hirata
- 1 Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan ; 2 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan ; 3 Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
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Tomas C, Soyer P, Dohan A, Dray X, Boudiaf M, Hoeffel C. Update on imaging of Peutz-Jeghers syndrome. World J Gastroenterol 2014; 20:10864-10875. [PMID: 25152588 PMCID: PMC4138465 DOI: 10.3748/wjg.v20.i31.10864] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant disease linked to a mutation of the STK 11 gene and is characterized by the development of benign hamartomatous polyps in the gastrointestinal tract in association with a hyperpigmentation on the lips and oral mucosa. Patients affected by PJS have an increased risk of developing gastrointestinal and extra-digestive cancer. Malignancy most commonly occurs in the small-bowel. Extra-intestinal malignancies are mostly breast cancer and gynecological tumors or, to a lesser extent, pancreatic cancer. These polyps are also at risk of acute gastrointestinal bleeding, intussusception and bowel obstruction. Recent guidelines recommend regular small-bowel surveillance to reduce these risks associated with PJS. Small-bowel surveillance allows for the detection of large polyps and the further referral of selected PJS patients for endoscopic enteroscopy or surgery. Video capsule endoscopy, double balloon pushed enteroscopy, multidetector computed tomography and magnetic resonance enteroclysis or enterography, all of which are relatively new techniques, have an important role in the management of patients suffering from PJS. This review illustrates the pathological, clinical and imaging features of small-bowel abnormalities as well as the role and performance of the most recent imaging modalities for the detection and follow-up of PJS patients.
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Management of duodenal-jejunal polyps in children with peutz-jeghers syndrome with single-balloon enteroscopy. J Pediatr Gastroenterol Nutr 2014; 59:49-53. [PMID: 24590213 DOI: 10.1097/mpg.0000000000000351] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Children with Peutz-Jeghers syndrome (PJS) have increased risk of polyp-related complications and emergency laparotomies. The aim of the present study was to assess the efficacy and the safety of endoscopic therapy of small bowel polyps using single-balloon enteroscopy (SBE) in children affected by PJS. METHODS Between January 2010 and December 2011, prospectively consecutive PJS children with polyps >15 mm or polyps actively bleeding previously identified using video capsule endoscopy and magnetic resonance imaging underwent therapeutic SBE. The main outcome measurements were the feasibility, the technical performance, and the safety. RESULTS A total of 10 children (6 boys; median age 13.7 years, range 5.6-15.6) underwent 23 SBE procedures. Four patients had a history of abdominal surgery. A total of 53 polyps were removed, and 23 of them were >15 mm. The majority of polyps were found in jejunum (85%). The mean insertion depths for antegrade and retrograde approach were 200 ± 80 and 100 ± 50 cm beyond the ileal valve, respectively. The mean procedure time was 75 ± 25 minutes. Mild abdominal pain was reported after 3 procedures. In 1 patient a postpolypectomy perforation occurred. CONCLUSIONS In conclusion, SBE is an effective endoscopic tool for treating small bowel polyps in children with PJS, and well-timed polypectomy may optimize patients' care, preventing polyp-related complications and emergency laparotomy. Further larger multicenter studies are warranted to accurately determine the safety of therapeutic SBE in children.
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Islam RS, Leighton JA, Pasha SF. Evaluation and management of small-bowel tumors in the era of deep enteroscopy. Gastrointest Endosc 2014; 79:732-40. [PMID: 24365041 DOI: 10.1016/j.gie.2013.11.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 11/01/2013] [Indexed: 12/13/2022]
Abstract
In summary, small-intestine tumors are a rare phenomenon, but they are being discovered more frequently with newer diagnostic techniques. Prior studies of the small bowel were limited, making the diagnosis difficult. With the advent of CE and deep enteroscopy, gastroenterologists are finding these tumors at an earlier stage, thereby offering better management options for these patients. Although the incidence of small-bowel tumors has increased, the survival rates have remained the same. This may be a lag-time bias but could be a future area of research in this emerging field.
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Affiliation(s)
- R Sameer Islam
- Division of Gastroenterology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Shabana F Pasha
- Division of Gastroenterology, Mayo Clinic, Scottsdale, Arizona, USA
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Abstract
PURPOSE OF REVIEW Small bowel capsule endoscopy (SBCE) was introduced 13 years ago by Given Imaging (Yokneam, Israel). It has become one of the most important investigational tools of the small bowel. The capsule is swallowed with water after a 12 h fast, propelled via peristalsis through the gastrointestinal tract and excreted naturally. A nonvideo patency capsule was developed to confirm functional patency of the gastrointestinal tract. RECENT FINDINGS Four additional companies have introduced competitive small bowel video capsules, some of which are Food and Drug Admistration (FDA) approved. Due to the easiness of the procedure, SBCE has become a first-line tool to detect small bowel abnormalities. The main indications for SBCE include obscure gastrointestinal bleeding, suspected Crohn's disease, small bowel tumors and practically any abnormal small bowel imaging. New indications are emerging like small bowel motility and monitoring of drug therapy and mucosal healing. The present review will describe the available capsules in the market, the procedure itself, present indications and future expectations. It will focus on the PillCam SB of Given Imaging as it is the one on which most of the literature is written. SUMMARY Over the past 10 years, SBCE has become a routine, first-line investigational tool of many small bowel pathologies.
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Abstract
Advances in small bowel enteroscopy have led to an increase in the endoscopic evaluation and management of small bowel disorders. The entire small bowel can now be visualized in a noninvasive manner by capsule endoscopy, while therapeutic management can be performed with deep enteroscopy techniques, including balloon-assisted and spiral enteroscopy. Each of these enteroscopy tools has its unique advantages and disadvantages, which need to be taken into consideration during selection of the appropriate tool. Capsule endoscopy and deep enteroscopy are often used as complementary tests in the evaluation of small bowel disorders.
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Affiliation(s)
- Shabana F Pasha
- Division of Gastroenterology, Department of Internal Medicine, Mayo Clinic College of Medicine, Scottsdale, AZ 85259, USA.
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Thomson ABR, Chopra A, Clandinin MT, Freeman H. Recent advances in small bowel diseases: Part II. World J Gastroenterol 2012; 18:3353-74. [PMID: 22807605 PMCID: PMC3396188 DOI: 10.3748/wjg.v18.i26.3353] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 04/05/2012] [Accepted: 04/13/2012] [Indexed: 02/06/2023] Open
Abstract
As is the case in all areas of gastroenterology and hepatology, in 2009 and 2010 there were many advances in our knowledge and understanding of small intestinal diseases. Over 1000 publications were reviewed, and the important advances in basic science as well as clinical applications were considered. In Part II we review six topics: absorption, short bowel syndrome, smooth muscle function and intestinal motility, tumors, diagnostic imaging, and cystic fibrosis.
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Small bowel diagnostics: current place of small bowel endoscopy. Best Pract Res Clin Gastroenterol 2012; 26:209-20. [PMID: 22704565 DOI: 10.1016/j.bpg.2012.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 03/08/2012] [Indexed: 01/31/2023]
Abstract
The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Until the end of the last century, the small bowel follow through was the primary diagnostic tool for suspected small bowel disease. In recent years capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computerized tomography and magnetic resonance enteroclysis or enterography have facilitated the diagnosis, monitoring, and management of patients with small bowel diseases. These technologies are complementary, each with its advantages and limitations. In the present article, we will discuss the different options and indications for modern diagnostic methods for visualization of the small bowel. We also try to provide a clinical rationale for the use of these different diagnostic options in less established, newly emerging, indications for small bowel evaluation.
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Small bowel endoscopy and Peutz-Jeghers syndrome. Best Pract Res Clin Gastroenterol 2012; 26:263-78. [PMID: 22704569 DOI: 10.1016/j.bpg.2012.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 01/18/2012] [Accepted: 03/22/2012] [Indexed: 01/31/2023]
Abstract
Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant inherited disease. It is clinically characterized by the development of gastrointestinal hamartomas, mainly located in the small bowel. These hamartomas are prone to complications such as intussusceptions, abdominal complaints and anaemia. Furthermore, patients are at increased risk for developing small bowel cancer. Therefore, regular surveillance of the small bowel is indicated. However, the optimal strategy for surveillance has not been determined yet. This review gives an overview of the different techniques that have been described to examine the small bowel of PJS patients. First, a number of radiologic and endoscopic imaging modalities with diagnostic value are discussed. Secondly, recently developed advanced endoscopy techniques are described that can serve both as a diagnostic and therapeutic tool in the surveillance of the small bowel. Finally, a recommendation is given how to apply these individual techniques for small bowel surveillance in a step-up approach.
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Diagnostic yield of deep enteroscopy techniques for small-bowel bleeding and tumors. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012. [DOI: 10.1016/j.tgie.2012.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Xie HM, Li JX, Yang XK. Characteristics of the small intestine revealed by capsule endoscopy in 53 patients with gastrointestinal disorders. Shijie Huaren Xiaohua Zazhi 2012; 20:430-433. [DOI: 10.11569/wcjd.v20.i5.430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the characteristics of the small intestine of patients with gastrointestinal disorders by capsule endoscopy.
METHODS: Fifty-three patients who underwent MiroCam capsule endoscopy from August 2010 to August 2011 were included in the study. According to clinical data, the patients were classified as having obscure gastrointestinal bleeding, suspected functional gastrointestinal disease, abdominal pain, diarrhea, and abdominal distension. The characteristics of the normal or abnormal small bowel were analyzed.
RESULTS: Of 53 patients, one failed capsule endoscopy due to the absence of signal, and one could not successfully complete the examination procedure for personal reason. The capsule endoscope reached the colon in the remaining 51 cases (96.22%). The average time for the passage of the capsule endoscope to the stomach and small intestine is 69.78 and 513.25 min, respectively. Capsule endoscopy revealed abnormal changes in 48 cases, and the positive rate is 90.57%. For all 51 patients with suspected small bowel disease, the overall positive diagnosis rate of intestinal lesions was 92.15% (47/51), and that of jejunal and ileal lesions was 52.94%, including 12 cases of non-specific inflammation (1 patient diagnosed with Crohn's disease), 3 cases of polyps, 3 cases of unknown mass, 1 case of hyperplasia of lymphoid follicles, 7 cases of intestinal lymphangiectasia, and 1 case of hookworm disease. In addition, 1 case of of reflux esophagitis, 26 cases of chronic gastritis, 7 cases of erosive gastritis, 3 cases of stomach polyps, 5 cases of colon polyps, 3 cases of colitis, and 2 cases of colon melanosis were found. Capsules were removed from the body naturally, and no complications such as obstruction occurred.
CONCLUSION: MiroCam capsule endoscopy is a safe and non-invasive means of revealing small intestinal lesions.
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Abstract
The two main problems in the management of the gastrointestinal tract in patients with Peutz-Jeghers syndrome (PJS) are the long term cancer risk and managing polyp related complications, such as intussusception and bleeding. In this article we will focus mainly on the clinical management of these problems. We will highlight some of the controversies regarding gastrointestinal PJS polyps, cancer development and cancer risk. We will review the available literature, particularly focusing on clinical data, to provide insights into these controversies. We describe guidelines for the surveillance and management of gastrointestinal polyps in PJS and review the data behind current recommendations.
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Terauchi S, Snowberger N, Demarco D. Double-balloon endoscopy and Peutz-Jeghers syndrome: a new look at an old disease. Proc AMIA Symp 2011; 19:335-7. [PMID: 17106494 PMCID: PMC1618735 DOI: 10.1080/08998280.2006.11928195] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Peutz-Jeghers syndrome is a rare disease characterized by mucocutaneous hyperpigmentation and intestinal hamartomatous polyposis. Life-threatening complications include intestinal obstruction and increased risk of gastrointestinal malignancies. While colonoscopy continues to serve as the gold standard for examination of the colon, newer techniques such as capsule endoscopy and double-balloon endoscopy (DBE) are now being applied to both treatment and surveillance of this disease. Capsule endoscopy serves as a minimally invasive means of locating and characterizing polyps in symptomatic patients but is limited to detection only. DBE allows physicians to visit areas of the small bowel that were previously unreachable by older techniques and to treat lesions that are found. By using DBE to treat polyposis, hemorrhagic ulcers, angiodysplasia, strictures, and cancers, the number of small bowel resections can be decreased in these patients.
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Affiliation(s)
- Stephanie Terauchi
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas, USA.
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Abstract
PURPOSE OF REVIEW Endoscopic investigation of small bowel disorders in children has historically been difficult due to the length and tortuosity of the organ itself. New technology introduced over the past decade allows minimally invasive, detailed endoscopic evaluation of the small bowel mucosa from the duodenum to the cecum. While understudied in the pediatric population, literature is emerging supporting the use of these techniques and devices in children. RECENT FINDINGS Well tolerated and clinically useful capsule endoscopy has been reported a number of times in children, and the indications and potential complications of this procedure are discussed. The limitations of capsule endoscopy, namely inability to biopsy and treat small bowel lesions, have been addressed to some extent by the introduction of balloon enteroscopy, which allows deep intubation of the small bowel, and at times viewing of the entire mucosal surface. Balloon enteroscopy has been safely reported in children as small as 13.1 kg, and has been successfully performed in children with Roux-en-Y anastomoses in the evaluation and therapy of biliary strictures. SUMMARY New enteroscopic techniques now allow detailed investigation and therapy of small bowel lesions in a minimally invasive fashion in the pediatric population.
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Sakamoto H, Yamamoto H, Hayashi Y, Yano T, Miyata T, Nishimura N, Shinhata H, Sato H, Sunada K, Sugano K. Nonsurgical management of small-bowel polyps in Peutz-Jeghers syndrome with extensive polypectomy by using double-balloon endoscopy. Gastrointest Endosc 2011; 74:328-33. [PMID: 21704992 DOI: 10.1016/j.gie.2011.04.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 04/01/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND The major problem in the management of Peutz-Jeghers syndrome (PJS) is small-bowel polyps, which can cause intussusception and bleeding. Double-balloon endoscopy (DBE) enables endoscopic resection of small-bowel polyps. OBJECTIVE The aim of this study was to determine the efficacy and safety of endoscopic management of small-bowel polyps in PJS patients by using DBE. DESIGN Retrospective chart review. SETTING Single university hospital. PATIENTS Consecutive patients with PJS who underwent multiple sessions of DBE for evaluation or treatment of small-bowel polyps between September 2000 and April 2009. INTERVENTIONS Endoscopic resection of small-bowel polyps in PJS patients was performed by using DBE. MAIN OUTCOME MEASUREMENTS Efficacy, safety, and long-term laparotomy rate after the procedures were evaluated. RESULTS Fifteen patients (10 men, mean age 34.0 ± 15.8 years) underwent DBE for a mean 3.0 ± 1.0 sessions. The mean numbers of resected polyps larger than 20 mm significantly decreased as sessions advanced (first, 3.6; second, 1.3; third, 0.7; fourth, 0.4; and fifth, 1.0; P = .02). The mean maximum sizes of resected polyps also significantly decreased at each session: 33, 19, 12, 17, and 30 mm (P = .01). One patient had a perforation, but was managed conservatively. Other complications were pancreatitis (n = 2) and bleeding (n = 2). Only 1 patient underwent surgery for intussusception during the study period. LIMITATIONS This was a small single-center retrospective study of short duration. CONCLUSIONS Endoscopic management of small-bowel polyps in PJS patients by using DBE is safe and effective and avoids urgent laparotomy.
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Affiliation(s)
- Hirotsugu Sakamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
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Dupont-Lucas C, Bellaïche M, Mouterde O, Bernard O, Besnard M, Campeotto F, Languepin J, Mosca A, Goulet O, Vannerom PY, Mougenot JF, Cardey J, Cézard JP, Viala J. [Capsule endoscopy in children: which are the best indications?]. Arch Pediatr 2011; 17:1264-72. [PMID: 20627490 DOI: 10.1016/j.arcped.2010.04.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 01/18/2010] [Accepted: 04/27/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND STUDY AIMS Capsule endoscopy (CE) is a novel and noninvasive means of investigating the small bowel. In children, the best CE indications have not yet been fully appraised. The aim of this study was to evaluate the diagnostic yield of CE in different pediatric pathologies. PATIENTS AND METHODS We retrospectively reviewed every CE performed in children in two French pediatric hospitals between March 2002 and June 2009. Seventy-nine CEs were performed on 70 children (mean age, 10.6 years; range, 2.2-18.0); 52 boys and 18 girls. The indications were iron deficiency anemia (24%), obscure gastrointestinal bleeding (14%), polyposis syndromes (16%), suspected Crohn disease (15%), unresponsive Crohn disease (10%), graft-versus-host disease (10%), and other (10%). RESULTS Of the 79 CEs, 69 reached the cecum (87%). Only one occlusion occurred in a case of stenosing Crohn disease, requiring surgical removal. In addition, technical difficulties led to an incomplete small bowel study in 12 cases (16%). The CE showed small bowel lesions in 42 cases (53%). The diagnostic yield was 27% in obscure gastrointestinal bleeding, 37% in iron-deficiency anemia, 42% in suspected Crohn disease, 88% in unresponsive Crohn disease, 62% in polyposis syndromes, and 88% in graft-versus-host disease. CONCLUSION In children, CE is well tolerated and can be performed in children as young as 2.2 years of age. Its diagnostic yield is highest in polyposis syndromes, unresponsive Crohn disease, and graft-versus-host disease.
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Affiliation(s)
- C Dupont-Lucas
- Service de pédiatrie, hôpital Femme-Enfant-Hématologie, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex 09, France.
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Abstract
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.
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Management of small-bowel polyps in Peutz-Jeghers syndrome by using enteroclysis, double-balloon enteroscopy, and videocapsule endoscopy. Gastrointest Endosc 2010; 72:1209-16. [PMID: 20970791 DOI: 10.1016/j.gie.2010.08.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 08/01/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Management of small-bowel polyps in Peutz-Jeghers syndrome (PJS) by using fluoroscopic enteroclysis (FE), double-balloon enteroscopy (DBE), and videocapsule enteroscopy (VCE) remains incompletely determined. OBJECTIVE To evaluate the usefulness of FE, VCE, and DBE and compute the polyp growth rate. DESIGN Single-center retrospective study. SETTING Tertiary referral hospital. PATIENTS Between June 2003 and January 2010, 18 consecutive patients with PJS were enrolled. MAIN OUTCOME MEASUREMENTS Polyp detection rates among FE, VCE, and DBE, histology of resected polyps, and the polyp growth rate. RESULTS Total enteroscopy rate was higher at VCE (89%) than at DBE (52%; 27% in patients with ≥2 previous laparotomies and 90% in patients with ≤1 [P = .001]). FE demonstrated fewer polyps than DBE, whereas VCE had detection rates similar to those of DBE. Of 387 DBE-resected and 22 surgically resected polyps, histologic analysis of 110 retrieved polyps showed adenoma or adenocarcinoma in 30.0% of polyps >20 mm and in only 1.3% of polyps ≤20 mm (P < .0001). Multiple linear regression analysis showed that the number of small-bowel polyps >10 mm (X1; P = .0366) and colorectal polyps >5 mm (X2; P = .002) were independent predictors of the growth rate of small-bowel polyps (Y), and a forward stepwise selection model was constructed: Y = 0.136 × X1 + 0.289 × X2 - 0.589 (R(2) = 0.665). LIMITATIONS Small sample size. CONCLUSIONS DBE and VCE were useful for the management of small-bowel polyps in PJS. VCE may replace barium examinations for surveillance after polyp resection at intervals depending on the polyp growth rate.
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Abstract
Capsule endoscopy (CE) has evolved in a few short years to become a first-line, noninvasive diagnostic technique for the small bowel. CE is now being utilized worldwide to assess patients for obscure gastrointestinal bleeding, possible Crohn's disease, celiac disease and small bowel tumors. The device is now used in tandem with balloon enteroscopy to direct therapeutic interventions. Alterations and improvements in CE have also led to the evaluation of both the esophagus and colon. It can be anticipated that in the near future pan CE of the entire GI tract will be performed, as well as possible tissue acquisition, drug delivery and therapeutic interventions.
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Affiliation(s)
- Noel M Lee
- University of Wisconsin, 600 Highland Ave, Madison, WI, USA.
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A prospective study of MR enterography versus capsule endoscopy for the surveillance of adult patients with Peutz-Jeghers syndrome. AJR Am J Roentgenol 2010; 195:108-16. [PMID: 20566803 DOI: 10.2214/ajr.09.3174] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of our study was to assess the utility of MR enterography compared with capsule endoscopy for the detection of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS). SUBJECTS AND METHODS Adult patients with PJS scheduled for surveillance capsule endoscopy were prospectively recruited and underwent MR enterography and capsule endoscopy. Polyps > 10 mm were regarded as clinically relevant. When appropriate, large polyps (> 15 mm) were removed at enteroscopy, enabling correlation with MR enterography and capsule endoscopy findings. Interobserver agreement for MR enterography and capsule endoscopy was calculated. Patient comfort, convenience, and test preference were assessed. RESULTS Nineteen patients (median age, 39.6 years) underwent both procedures. There was no significant difference between techniques for the detection of polyps > 10 mm (18 vs 23 polyps at capsule endoscopy and MR enterography, respectively; p = 0.35) or in the number of patients in whom > 10 mm polyps were detected (eight vs 11 patients at capsule endoscopy and MR enterography, respectively; p = 0.38). However, in three patients, large polyps (> 15 mm) detected on MR enterography were not detected on capsule endoscopy; large polyps were seen in six patients at capsule endoscopy and in nine patients at MR enterography (p = 0.25). Interobserver agreement was high for MR enterography but was only fair for capsule endoscopy (kappa = 0.81 and 0.27, respectively). Size assessments of large polyps (> 15 mm) appeared more reproducible with MR enterography than with capsule endoscopy. Patients rated capsule endoscopy as more comfortable than MR enterography. There was no significant difference between the techniques with regard to patient convenience or preference. CONCLUSION MR enterography is a promising alternative to capsule endoscopy for small-bowel surveillance in adults with PJS. Although our results suggest that capsule endoscopy is more comfortable for the patient, MR enterography may be less prone to missing large polyps and may be more reliable in their size assessment.
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McAlindon ME, Sanders DS, Sidhu R. Capsule endoscopy: 10 years on and in the frontline. Frontline Gastroenterol 2010; 1:82-87. [PMID: 28839553 PMCID: PMC5517174 DOI: 10.1136/fg.2009.000463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2010] [Indexed: 02/04/2023] Open
Abstract
Capsule endoscopy is a safe, simple, remote method of visualising the gastrointestinal tract without resorting to conventional endoscopic intubation or radiation exposure. In addition, the ability to visualise the small bowel mucosa directly means that it is considerably more sensitive than existing small bowel imaging modalities in detecting subtle abnormalities. It is a firstline investigative modality for suspected small bowel bleeding and is being increasingly used for detecting evidence of other small bowel diseases. In Crohn's disease, it can confirm evidence of activity without recourse to repeated endoscopic intubation or radiation but does not replace MRI and CT which are better suited to defining stricturing disease and transmural complications. The production of different capsule endoscopes to examine the oesophagus, small bowel and colon now means that almost all of the gut can be examined using this technology.
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Affiliation(s)
- M E McAlindon
- Small Bowel and Nutrition Unit, Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - D S Sanders
- Small Bowel and Nutrition Unit, Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - R Sidhu
- Small Bowel and Nutrition Unit, Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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High cancer risk in Peutz-Jeghers syndrome: a systematic review and surveillance recommendations. Am J Gastroenterol 2010; 105:1258-64; author reply 1265. [PMID: 20051941 DOI: 10.1038/ajg.2009.725] [Citation(s) in RCA: 301] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disorder associated with increased cancer risk. Surveillance and patient management are, however, hampered by a wide range in cancer risk estimates. We therefore performed a systematic review to assess cancer risks in PJS patients and used these data to develop a surveillance recommendation. METHODS A systematic PubMed search was performed up to February 2009, and all original articles dealing with PJS patients with confirmed cancer diagnoses were included. Data involving cancer frequencies, mean ages at cancer diagnosis, relative risks (RRs), and cumulative risks were collected. RESULTS Twenty-one original articles, 20 cohort studies, and one meta-analysis fulfilled the inclusion criteria. The cohort studies showed some overlap in the patient population and included a total of 1,644 patients; 349 of them developed 384 malignancies at an average age of 42 years. The most common malignancy was colorectal cancer, followed by breast, small bowel, gastric, and pancreatic cancers. The reported lifetime risk for any cancer varied between 37 and 93%, with RRs ranging from 9.9 to 18 in comparison with the general population. Age-related cumulative risks were given for any cancer and gastrointestinal, gynecological, colorectal, pancreatic, and lung cancers. CONCLUSIONS PJS patients are markedly at risk for several malignancies, in particular gastrointestinal cancers and breast cancer. On the basis of these elevated risks, a surveillance recommendation is developed to detect malignancies in an early phase and to remove polyps that may be premalignant and may cause complications, so as to improve the outcome.
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Abstract
PURPOSE OF REVIEW It is now over 8 years since small bowel capsule endoscopy (SBCE) was first introduced to the gastrointestinal community. The original capsule (Given Imaging, YoKneam, Israel) - a disposable 26 x 11 mm video capsule containing its own optical dome, light source, batteries, transmitter and antenna - is swallowed with water after a 12 h fast. The capsule is propelled via peristalsis through the gastrointestinal tract and is excreted naturally. We will review all recent work concerning SBCE. RECENT FINDINGS At present there are three other SBCEs in the market. SBCE has become a first-line tool to detect abnormalities in the small bowel, as all other imaging technologies are rather ineffective, or very tedious.Indications for SBCE include obscure gastrointestinal bleeding, suspected small bowel tumor, suspected Crohn's disease, surveillance of inherited polyposis syndromes, drug-induced small bowel injury or any abnormal small bowel imaging and new ones are emerging like small bowel motility. Since most of the articles in the literature relate to the PillCam small bowel capsule the data presented will refer mainly to this capsule endoscopy. SUMMARY SBCE has shed new light into our knowledge of the small bowel, paving the way for new modalities to come.
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Feasibility of video capsule endoscopy in the management of children with Peutz-Jeghers syndrome: a blinded comparison with barium enterography for the detection of small bowel polyps. J Pediatr Gastroenterol Nutr 2009; 49:417-23. [PMID: 19543117 DOI: 10.1097/mpg.0b013e31818f0a1f] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Peutz-Jeghers syndrome (PJS) in children may present with anaemia, intussusception, or obstruction from an early age and surgery is common. Prophylactic polypectomy may reduce subsequent complications. Traditional barium enterography (BE) has poor sensitivity and requires significant radiation. We compared the performance of capsule endoscopy (CE) with BE in children with PJS. MATERIALS AND METHODS Children with PJS (ages 6.0-16.5 years) were prospectively recruited and underwent BE followed by CE, each reported by expert reviewers blinded to the alternate modality. Number of "significant" (>10 mm) and total number of polyps were recorded. Child preference was assessed using a visual analogue questionnaire. Definitive findings were assessed at laparotomy or enteroscopy, when performed. RESULTS There was no significant difference for >10 mm polyp detection. Six polyps were found in 3 children by both modalities: 3 polyps in 2 children at CE, 3 polyps in 1 child at BE (P=0.50). Re-review of 1 CE identified 3 polyps that were missed in 1 child at initial reading. Significantly more <10 mm polyps were identified by CE than BE: 61 vs 6 (P=0.02). CE was significantly more comfortable than BE (median score CE 76 [interquartile range 69-87] vs BE 37 [interquartile range 31-68], P=0.03) and was the preferred investigation in 90% (P=0.02). CONCLUSIONS CE is a feasible, safe, and sensitive test for small bowel polyp surveillance in children with PJS. It is significantly more comfortable than BE and is the preferred test of most children for future surveillance. There is a learning curve for reporting CE studies in PJS and appropriate training is essential.
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Sacher-Huvelin S, Bourreille A, Le Rhun M, Galmiche JP. [Future prospects in digestive endoscopy: wireless capsule endoscopy]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2009; 33:747-757. [PMID: 19679416 DOI: 10.1016/j.gcb.2009.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Since the beginning of the millennium, the development of wireless capsule endoscopy has represented a major technological advance. The capsule is ingested by the patient and images are transmitted via several sensors positioned on the skin of the patient and downloaded in a computer system. The first applications were focused on the exploration of the small bowel which was previously considered as an obscure area for conventional endoscopy. Wireless capsule endoscopy of the small bowel is now an established technique with many acknowledged indications for the diagnosis of obscure bleeding, anemia of presumed digestive origin, Crohn's disease and small bowel tumors. Recently, thanks to technological progresses, novel capsules have been developed for specific segments of the gut namely the oesophagus and the colon. Recent data suggest that these new capsules could have potential applications for the diagnosis of oesophageal varices, Barrett's oesophagus and for the screening and/or surveillance of polyps of the colon. However, further studies are required before such strategies could be approved for clinical use or even replace conventional endoscopic modalities. In the long-term, progresses in signal processing as well as in the miniaturisation of sensors or markers may lead to a new generation of endoscopic robots. This technological breakthrough may ultimately result in new concepts and change current practice of digestive endoscopy.
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Affiliation(s)
- S Sacher-Huvelin
- Institut des Maladies de l'Appareil Digestif, CIC-Inserm, Hôtel-Dieu, CHU de Nantes, Université de Nantes, 44093 Nantes cedex, France
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Postgate A, Haycock A, Thomas-Gibson S, Fitzpatrick A, Bassett P, Preston S, Saunders BP, Fraser C. Computer-aided learning in capsule endoscopy leads to improvement in lesion recognition ability. Gastrointest Endosc 2009; 70:310-6. [PMID: 19386301 DOI: 10.1016/j.gie.2008.11.043] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Accepted: 11/20/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND The rapid expansion in use of capsule endoscopy (CE) has led to discussion about training needs and provision. The lesion recognition skills required for CE are ideally suited to computer-based training. OBJECTIVE The aim of this study was to prospectively evaluate the educational effectiveness of a computer-based CE training and testing module on trainees with varying experience. DESIGN This was a prospective educational evaluation study. SETTING Academic endoscopy unit. PATIENTS This study involved 28 trainees of varying CE experience (medical students, gastroenterology trainees) and 4 CE experts. INTERVENTION Trainees (medical students and gastroenterology trainees) without CE experience completed a 60-question, computer-based test module consisting of 30-second video clips and multiple-choice questions. Without feedback, trainees then completed a comprehensive, menu-driven, computer-based CE training module. The test module was then completed a second time and feedback was given. Expert performance on the test module was benchmarked by 4 CE experts. MAIN OUTCOME MEASUREMENTS The first measure was the difference in baseline performance on the test module between trainees and experts (to determine construct validity). The second measure was a change in performance on the test module after training (to determine content validity of the training module). RESULTS A significant difference was noted in baseline performance (P < .001) among CE experts (mean 73.8% +/- 8.0%), gastroenterology trainees (49.5% +/- 10.9%), and medical students (29.5% +/- 3.3%). Performance improved significantly (P < .001) in both trainee groups after training (gastroenterology trainees' posttraining score 62.1% +/- 7.7%; medical students' 46.7% +/- 6.8%). CONCLUSION Computer-based learning has a potentially significant role in the development of a training syllabus for CE and in CE accreditation.
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Affiliation(s)
- Aymer Postgate
- Wolfson Unit for Endoscopy, Imperial College London, St Mark's Hospital, London, United Kingdom.
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How should we train capsule endoscopy? A pilot study of performance changes during a structured capsule endoscopy training program. Dig Dis Sci 2009; 54:1672-9. [PMID: 19034658 DOI: 10.1007/s10620-008-0558-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Accepted: 09/26/2008] [Indexed: 12/18/2022]
Abstract
There are no validated training/accreditation guidelines for capsule endoscopy. We assessed the utility of a structured training program on two experienced gastroenterologists and one endoscopy nurse. Validated studies were standardized for difficulty in blocks of three. Trainees completed a standardized data sheet for each study reported (12 studies for the physicians, 22 studies for the nurse). After each block the trainer graded performance and highlighted learning points. Statistical analysis was performed. Physician trainees accurately identified landmarks throughout, while the nurse made errors even at the end of training. Improvement in lesion detection and diagnostic accuracy improved in the nurse, but in only one of the physician trainees, highlighting the variability in learning curves. Overall performance improved in all trainees but was most marked for the nurse trainee (correlation coefficient 0.41, P = 0.06). Improvements in lesion recognition and diagnosis can be demonstrated in senior trainees and nurses following a structured training program; however, there is considerable variability.
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Abstract
Although rare, small bowel tumors may cause significant morbidity and mortality if left undetected. New endoscopic modalities allow full examination of the small bowel with improved diagnosis. However, isolated mass lesions may be missed by capsule endoscopy or incomplete balloon-assisted enteroscopy. Therefore the use of radiologic imaging and intraoperative enteroscopy for diagnosis should not be forgotten. Endoscopic resection of small bowel polyps and certain vascular tumors is possible but requires proper training. Advances in endoscopic tools are likely to broaden the endoscopic management of small bowel tumors. This article describes the general features of small bowel tumors, clinical presentation, and diagnostic tests followed by a description of the more common tumor types and their management.
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Affiliation(s)
- Shirley C Paski
- Section of Gastroenterology, Department of Internal Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
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Rey JF, Repici A, Kuznetsov K, Boyko V, Aabakken L. Optimal preparation for small bowel examinations with video capsule endoscopy. Dig Liver Dis 2009; 41:486-93. [PMID: 19158002 DOI: 10.1016/j.dld.2008.09.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 09/08/2008] [Accepted: 09/11/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Video capsule endoscopy is a major advance for small bowel exploration. Although the clinical benefit is well accepted, there are still unresolved issues concerning patient preparation. AIM This study was set up in order to clarify the clinical benefit of small bowel preparation and give advices in order to obtain the best results for this expensive device. METHOD 116 patients were randomised in 3 centres between two preparations from the traditional liquid diet versus polyethylene glycol colonoscopy-like preparation. External viewer monitoring and recording pictures were focused on image quality, bubbles or diet residues. Picture qualities were assessed blindly. RESULTS For jejunal exploration no differences were noticed between the two preparations but for the ileum, polyethylene glycol preparation gives significant better results than liquid diet: air bubbles (64.4% versus 29.8% p<0.05); opaque residue (83.1% versus 38.6% p<0.05). External viewer was useful in order to use prokinetic drugs in case of delayed gastric emptying. CONCLUSION The result leads to a new advice for colleagues in handling patients in order to improve the diagnosis yield by using a modified polyethylene glycol preparation.
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Affiliation(s)
- J-F Rey
- Institut Arnault Tzanck, Saint Laurent du Var, France.
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45
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Abstract
Colon polyps are a common finding in pediatrics and can present with rectal bleeding, abdominal pain, or polyp prolapse from the rectum. Histologically classified as hamartomas, these isolated pediatric polyps lack epithelial dysplasia and have no cancer risk. However, when polyps are present in greater numbers, or are associated with a family history of polyps or colon or other cancers, a polyposis or hereditary colorectal cancer syndrome should be considered. Using a case-based format, this article reviews the clinical features and provides updates on the three most common hamartomatous polyp syndromes of childhood: juvenile polyposis syndrome, Peutz-Jeghers syndrome, and the PTEN hamartoma tumor syndrome. Each syndrome has distinctive intestinal and extra-intestinal findings that, when present, can guide genetic counseling and testing. Lifelong cancer surveillance is crucial to disease prevention and the long-term health of these patients and their families.
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Affiliation(s)
- Sherry C Huang
- Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH 43205, USA
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Postgate A, Tekkis P, Patterson N, Fitzpatrick A, Bassett P, Fraser C. Are bowel purgatives and prokinetics useful for small-bowel capsule endoscopy? A prospective randomized controlled study. Gastrointest Endosc 2009; 69:1120-8. [PMID: 19152909 DOI: 10.1016/j.gie.2008.06.044] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Accepted: 06/16/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Capsule endoscopy (CE) is limited by incomplete small-bowel transit and poor view quality in the distal bowel. Currently, there is no consensus regarding the use of bowel purgatives or prokinetics in CE. OBJECTIVE To evaluate the usefulness of bowel purgatives and prokinetics in small-bowel CE. DESIGN Prospective single-blind randomized controlled study. SETTING Academic endoscopy unit. PATIENTS A total of 150 patients prospectively recruited. INTERVENTION Patients were randomized to 1 of 4 preparations: "standard" (fluid restriction then nothing by mouth 12 hours before the procedure, water and simethicone at capsule ingestion [S]); "standard" + 10 mg oral metoclopramide before the procedure (M); Citramag + senna bowel-purgative regimen the evening before CE (CS); Citramag + senna + 10 mg metoclopramide before the procedure (CSM). MAIN OUTCOME MEASUREMENTS Gastric transit time (GTT) and small-bowel transit time (SBTT), completion rates (CR), view quality, and patient acceptability. SECONDARY OUTCOME MEASURES positive findings, diagnostic yield. RESULTS No significant difference was noted among groups for GTT (median [minutes] M, CS, and CSM vs S: 17.3, 24.7, and 15.1 minutes vs 16.8 minutes, respectively; P = .62, .18, and .30, respectively), SBTT (median [minutes] M, CS, and CSM vs S: 260, 241, and 201 vs 278, respectively; P = .91, .81, and .32, respectively), or CRs (85%, 85%, and 88% vs 89% for M, CS, and CSM vs S, respectively; P = .74, .74, and 1.00, respectively). There was no significant difference in view quality among groups (of 44: 38, 37, and 40 vs 37 for M, CS, and CSM, vs S, respectively; P = .18, .62, and .12, respectively). Diagnostic yield was similar among the groups. CS and CSM regimens were significantly less convenient (P < .001), and CS was significantly less comfortable (P = .001) than standard preparation. CONCLUSIONS Bowel purgatives and prokinetics do not improve CRs or view quality at CE, and bowel purgatives reduce patient acceptability.
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Affiliation(s)
- Aymer Postgate
- Wolfson Unit for Endoscopy, St. Mark's Hospital, Imperial College London, UK.
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Kav T, Bayraktar Y. Five years' experience with capsule endoscopy in a single center. World J Gastroenterol 2009; 15:1934-42. [PMID: 19399924 PMCID: PMC2675082 DOI: 10.3748/wjg.15.1934] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2009] [Revised: 03/19/2009] [Accepted: 03/26/2009] [Indexed: 02/06/2023] Open
Abstract
Capsule endoscopy (CE) is a novel technology that facilitates highly effective and noninvasive imaging of the small bowel. Although its efficacy in the evaluation of obscure gastrointestinal bleeding (OGIB) has been proven in several trials, data on uses of CE in different small bowel diseases are rapidly accumulating in the literature, and it has been found to be superior to alternative diagnostic tools in a range of such diseases. Based on literature evidence, CE is recommended as a first-line investigation for OGIB after negative bidirectional endoscopy. CE has gained an important role in the diagnosis and follow-up of Crohn's disease and celiac disease and in the surveillance of small bowel tumors and polyps in selected patients. Capsule retention is the major complication, with a frequency of 1%-2%. The purpose of this review was to discuss the procedure, indications, contraindications and adverse effects associated with CE. We also review and share our five-year experience with CE in various small bowel diseases. The recently developed balloon-assisted enteroscopies have both diagnostic and therapeutic capability. At the present time, CE and balloon-assisted enteroscopies are complementary techniques in the diagnosis and management of small bowel diseases.
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Abstract
BACKGROUND Peutz-Jeghers syndrome (PJS) is an autosomal dominant syndrome with an increased risk of polyposis complications and intestinal and extraintestinal tumours. METHODS During the last 15 years, we reviewed a series of 11 children with PJS, with special attention to evolution and follow-up. Diagnosis was based on at least 1 hamartomatous polyp associated with 2 of the 3 following criteria: family record of PJS, polyposis localised on small bowel, and mucocutaneous pigmentation. Diagnosis of PJS also could be raised by a single genetic analysis of STK11 gene. RESULTS Median age at beginning of symptoms was 6 years old. Seven of the 11 children had genetic tests, which were positive for STK11 gene mutation. Among the 10 children presenting with gastrointestinal complications, 8 were operated on, 6 had at least 1 small bowel resection, and 4 had repeat surgery for recurrent intussusceptions. In case of complications leading to a surgical procedure, we performed intraoperative enteroscopy to remove all large polyps. To prevent any polyposis complications, we suggest a complete check-up of polyposis topography with some of the new endoscopic tools, either double-balloon endoscopy or videocapsule endoscopy. CONCLUSIONS Children with PJS have a high risk of numerous laparotomies due to polyps' complications. Therefore, a screening of intestinal polyposis by videocapsule endoscopy is recommended, as well as a screening of the most frequent sites of cancers for the patient's whole life. During any abdominal procedure, they should have an intraoperative endoscopy, this management allowing an increased time interval between 2 laparotomies.
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Abstract
Recent developments in enteroscopy have been changing the diagnostic and therapeutic algorithm for diseases of the small bowel. In particular, double-balloon endoscopy has enabled the endoscopic treatment of small-bowel diseases. A majority of vascular lesions can now be treated endoscopically. The presence or absence of arterial components provides important information for selecting endoscopic treatments. In the case of Peutz-Jeghers syndrome, gastrointestinal screening of the small bowel should be started from childhood, and when polyps develop they should be managed by endoscopic resection as opposed to laparotomy. For familial adenomatous polyposis, duodenal and ampullary cancers are major causes of death after prophylactic colectomy. Intensive surveillance and treatment of such patients may lead to reduction of mortality related to duodenal cancer. The prognosis of malignant tumours of the small bowel was previously poor because early diagnosis was impossible. The new technologies have facilitated the diagnosis of these tumours, and improvements in the prognosis can be expected.
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Affiliation(s)
- T Yano
- Endoscopy Center, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
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Yano T, Yamamoto H. Current state of double balloon endoscopy: the latest approach to small intestinal diseases. J Gastroenterol Hepatol 2009; 24:185-92. [PMID: 19215331 DOI: 10.1111/j.1440-1746.2008.05773.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recent developments of capsule endoscopy and double balloon endoscopy (DBE) have made endoscopic examination of the entire small bowel practical, and changed the diagnostic algorithm for small bowel diseases. Double balloon endoscopy uses two balloons, one attached to the tip of the endoscope and another at the distal end of an overtube. By using these balloons to grip the intestinal wall, the endoscope can be inserted further without forming redundant loops of intestine. Total inspection by DBE is usually achieved by combination of sequential oral and anal intubations; success rates are reported to be 40-80%. Indications for DBE include scrutiny for obscure gastrointestinal bleeding, small bowel tumor, small bowel stricture and following up evaluation of previously diagnosed small bowel diseases. Because DBE has an accessory channel and good maneuverability in the distal small intestine, it enables endoscopic treatment, including hemostasis, balloon dilation, polypectomy, mucosal resection, retrieval of foreign bodies and endoscopic retrograde cholangiopancreatography (in the case of post-operative anastomoses). Double balloon endoscopy is also useful for cases of difficult colonoscopy, providing success rates of total colonoscopy between 88-100%. Although it has been a few years since its development, the usefulness of DBE is now well recognized. This challenging procedure has become popular rapidly and is currently used in many countries.
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Affiliation(s)
- Tomonori Yano
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Jichi Medical University, Shimotsuke, Tochigi, Japan
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