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Ponte A, Pinho R, Rodrigues A, Silva J, Rodrigues J, Sousa M, Carvalho J. Predictive factors of an incomplete examination and inadequate small-bowel cleanliness during capsule endoscopy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:605-611. [PMID: 29893576 DOI: 10.17235/reed.2018.4834/2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM the aim of this study was to determine predictive factors for an incomplete capsule endoscopy and an inadequate small-bowel preparation in capsule endoscopy. METHODS predictive factors for an incomplete capsule endoscopy were evaluated. Therefore, all patients with incomplete examinations performed between June 2009 and February 2016 were retrospectively included and compared with all patients with complete procedures performed between January 2014 and February 2016. Predictive factors of an inadequate small-bowel cleanliness were assessed. Therefore, the subset of patients that underwent capsule endoscopy between January 2014 and February 2016, including incomplete examinations, were evaluated. Small-bowel cleanliness was evaluated according to a quantitative index and a qualitative evaluation scale. Data with regard to patient and capsule endoscopy was analyzed. RESULTS 31 incomplete and 122 complete capsule endoscopies were included in the analysis of predictive factors for an incomplete capsule endoscopy. The degree of dependency (OR = 4.67; p = 0.028), performance of a capsule endoscopy in hospitalized patients (OR = 4.04; p = 0.006) and prior abdominal surgery (OR = 3.45; p = 0.012) were independent predictive factors of an incomplete procedure. 130 patients were included in the analysis of predictive factors for an inadequate small-bowel cleanliness. The mean quantitative index value was 7.3 (s.d. ± 2.3); 41.6% and 58.5% of capsule endoscopies were classified as poor-fair and good/excellent respectively, according to the qualitative evaluation. Independent predictive factors for an inadequate preparation according to the quantitative index included male gender (Beta = -0.79; p = 0.028), small-bowel transit time (Beta = -0.007; p < 0.0001) and cardiac disease (Beta = -1.29; p = 0.001). Associated factors according to the qualitative evaluation included male gender (OR = 0.406; p = 0.027) and small-bowel transit time (SBTT) (OR = 0.993; p < 0.0001). CONCLUSION inpatient status, higher degrees of dependency and abdominal surgery are predictive factors for an incomplete capsule endoscopy; male gender and higher small-bowel transit time are predictive factors for an inadequate cleanliness.
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Affiliation(s)
- Ana Ponte
- Gastrenterologia, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Rolando Pinho
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
| | | | - Joana Silva
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - Jaime Rodrigues
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - Mafalda Sousa
- Gastroenterology and Hepatology department, Centro Hospitalar de Gaia/Espinho
| | - João Carvalho
- Gastroenterology and Hepatology department, Centro Hospitalar de Gaia/Espinho, Portugal
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Oakland K, Chadwick G, East JE, Guy R, Humphries A, Jairath V, McPherson S, Metzner M, Morris AJ, Murphy MF, Tham T, Uberoi R, Veitch AM, Wheeler J, Regan C, Hoare J. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019; 68:776-789. [PMID: 30792244 DOI: 10.1136/gutjnl-2018-317807] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/07/2019] [Accepted: 01/16/2019] [Indexed: 01/28/2023]
Abstract
This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.
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Affiliation(s)
| | | | - James E East
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, UK
| | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Vipul Jairath
- Robarts Clinical Trials, Inc., London, Ontario, Canada.,Medicine and Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | | | - Magdalena Metzner
- Department of Gastroenterology, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - A John Morris
- Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Tony Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, UK
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - James Wheeler
- Department of Colorectal Surgery, Addenbrooke's Hospital, Cambridge, UK
| | | | - Jonathan Hoare
- Department of Surgery and Cancer, Imperial College, London, UK
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3
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Clinical outcomes of negative small-bowel capsule endoscopy for small-bowel bleeding: a systematic review and meta-analysis. Gastrointest Endosc 2017; 85:305-317.e2. [PMID: 27594338 DOI: 10.1016/j.gie.2016.08.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/23/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Small-bowel bleeding is the primary indication for capsule endoscopy (CE). Many experts advocate a "watch-and-wait" policy in negative CE. This meta-analysis examines the odds of rebleeding after negative index CE and the impact on long-term follow-up. METHODS A comprehensive literature search identified articles examining the rebleeding rate after negative CE. Demographic and clinical information with emphasis on outcomes was retrieved, pooled, and analyzed. Heterogeneity among studies was assessed using the I2 statistic. A random effects model was used as the pooling method because of high heterogeneity. Risk of bias was assessed using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. The primary outcome evaluated was the pooled odds ratios (ORs) for rebleeding after a negative CE for obscure GI bleeding (OGIB). RESULTS Twenty-six studies with 3657 patients were included. The pooled rate of rebleeding after negative CE was .19 (95% CI, .14-.25; P < .0001). The pooled OR of rebleeding was .59 (95% CI, .37-.95; P < .001). The effect was more pronounced in studies with a short follow-up (OR, .47; 95% CI, .24-.94; P < .001). There was no statistically significant difference in rebleeding after CE for occult and overt OGIB. Prospective studies showed a lower OR of rebleeding of .24 (95% CI, .08-.73; P = .01). Most studies were high quality. CONCLUSIONS Our analysis shows that negative CE provides adequate evidence of a subsequently low risk of rebleeding. Such patients can therefore be safely managed with watchful waiting. However, patients who rebleed after 2 years may need to be investigated for a new source of blood loss.
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Fernández-Urién I, Carretero C, González B, Pons V, Caunedo Á, Valle J, Redondo-Cerezo E, López-Higueras A, Valdés M, Menchen P, Fernández P, Muñoz-Navas M, Jiménez J, Herrerías JM. Incidence, clinical outcomes, and therapeutic approaches of capsule endoscopy-related adverse events in a large study population. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 107:745-52. [PMID: 26671587 DOI: 10.17235/reed.2015.3820/2015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Capsule endoscopy (CE) has become a first-line tool for small bowel (SB) examination. However, adverse events (AEs), such as CE retention or aspiration, may occur. The aims of this study were to evaluate incidence, clinical outcomes and therapeutic approaches of CE-related AEs in the largest series published to date. METHODS Data from 5428 procedures performed at 12 institutions between August 2001 and January 2012 were retrospectively analyzed. Baseline patient characteristics; procedure; type, localization and symptoms before/after AEs; previous patency tests performed; therapeutic management and patient's outcome were recorded. RESULTS The overall incidence of CE-related AEs was 1.9%: 2.0% for SB, 0.9% for esophageal and 0.5% for colon CE. The incidence of capsule retention was significantly higher than capsule aspiration (1.87% vs. 0.003%; p < 0.05), in patients suffering from inflammatory bowel disease (IBD) than in obscure GI bleeding (OGIB) (3.3% vs. 1.5%; p < 0.05) and in patients with the combination of nausea/vomiting, abdominal pain and distension. The SB was the most frequent localization of retention (88.2%). The use of patency tests -except for Patency© capsule- before CE was not a good predictor for AEs. Most of the patients with AEs developed no or mild symptoms (97%) and were managed by non-surgical methods (64.4%). CONCLUSIONS CE-related AEs are uncommon and difficult to predict by imagiological examinations. SB retention, that is usually asymptomatic, is the most frequent AE. In absence of symptoms, non-surgical management of CE-related AEs is recommended.
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Affiliation(s)
| | | | | | - Vicente Pons
- Hospital Universitario y Politécnico La Fe. Valencia
| | | | | | | | | | | | - Pedro Menchen
- Hospital General Universitario Gregorio Marañon Hospital. Madrid
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Gurudu SR, Bruining DH, Acosta RD, Eloubeidi MA, Faulx AL, Khashab MA, Kothari S, Lightdale JR, Muthusamy VR, Yang J, DeWitt JM. The role of endoscopy in the management of suspected small-bowel bleeding. Gastrointest Endosc 2017; 85:22-31. [PMID: 27374798 DOI: 10.1016/j.gie.2016.06.013] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/08/2016] [Indexed: 02/06/2023]
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Ormeci AC, Akyuz F, Baran B, Gokturk S, Ormeci T, Pinarbasi B, Mutluay Soyer O, Evirgen S, Akyuz U, Karaca C, Demir K, Kaymakoglu S, Besisik F. Retention during capsule endoscopy: Is it a real problem in routine practice? J Int Med Res 2016; 44:968-75. [PMID: 27377071 PMCID: PMC5536635 DOI: 10.1177/0300060516645420] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/29/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE This study evaluated the risks and outcomes of capsule retention during capsule endoscopy (CE) for investigating small bowel disease. Capsule retention is the most serious complication of CE. METHODS Before CE, the gastrointestinal tract was evaluated for blockages with computerized tomography. Analysis of CE was made retrospectively. RESULTS Capsule endoscopy was used to investigate obscure bleeding (90.2%; n = 324) or other symptoms (9.8%; n = 35). The capsule retention rate was 11/359 (3.1%); it was retained in a malignant lesion area (adenocarcinoma or melanoma) in two patients (18.2%), in the small bowel in an ulcerated area in five patients (45.5%), and in the oesophagus/stomach in four patients (36.4%) due to dysmotility. None of the patients had symptoms of obstruction. CONCLUSIONS Scanning patients before CE did not predict capsule retention. Retention is a complication of CE, but occurs as a result of the underlying disease. The risk of retention is increased in patients with motility disorders, suspected small bowel ulcers or malignancies.
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Affiliation(s)
- Asli Cifcibasi Ormeci
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Filiz Akyuz
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bulent Baran
- Department of Gastroenterology, Koç University Hospital, Istanbul, Turkey
| | - Suut Gokturk
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tugrul Ormeci
- Department of Radiology, Medipol University, Istanbul, Turkey
| | - Binnur Pinarbasi
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozlem Mutluay Soyer
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sami Evirgen
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Umit Akyuz
- Department of Gastroenterology, Yeditepe University, Istanbul, Turkey
| | - Cetin Karaca
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Kadir Demir
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sabahattin Kaymakoglu
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatih Besisik
- Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Analysis of Non-Small Bowel Lesions Detected by Capsule Endoscopy in Patients with Potential Small Bowel Bleeding. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2016; 2016:9063293. [PMID: 27092029 PMCID: PMC4820590 DOI: 10.1155/2016/9063293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/13/2016] [Indexed: 02/07/2023]
Abstract
Gastrointestinal (GI) bleeding cases in whom source cannot be identified after conventional upper and lower GI endoscopy are defined as potential small bowel bleeding. We aimed to search for lesions in the reach of conventional endoscopy in patients to whom video capsule endoscopy (VCE) had been applied for potential small bowel bleeding. 114 patients who had VCE evaluation for potential small bowel bleeding between January 2009 and August 2015 were retrospectively evaluated. Mean age of the patients was 55 ± 17 years. Female/male ratio is 39/75. In 58 patients (50.9%) bleeding lesion could be determined. Among these 58 patients 8 patients' lesions were in the reach of conventional endoscopes. Overall these 8 patients comprised 7% of patients in whom VCE was performed for potential small bowel bleeding. Among these 8 patients 5 had colonic lesions (4 angiodysplasia, 1 ulcerated polypoid cecal lesion), 2 had gastric lesions (1 GAVE, 1 anastomotic bleeding), and 1 patient had a bleeding lesion in the duodenal bulbus. Although capsule endoscopy is usually performed for potential small bowel bleeding gastroenterologists should always keep in mind that these patients may be suffering from bleeding from non-small bowel segments and should carefully review images captured from non-small bowel areas.
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8
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[Approach to the diagnosis and treatment of chronic anemia secondary to gastrointestinal diseases]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:573-82. [PMID: 25443541 DOI: 10.1016/j.gastrohep.2014.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 07/21/2014] [Accepted: 07/24/2014] [Indexed: 11/21/2022]
Abstract
Iron deficiency anemia is the most common type of anemia and can cause asthenia, cognitive and functional impairment, and decompensation of underlying diseases. Iron deficiency anemia is not a disease but is the result of a potentially serious medical problem. Consequently, patients should always undergo investigation of the underlying cause. In men and postmenopausal women, the condition is caused by gastrointestinal loss and malabsorption of iron. In this group, recommended procedures are gastroscopy, colonoscopy and serological testing for celiac disease. If the results of these tests are negative, repeat examinations and iron therapy should be considered. In treatment-refractory or recurrent anemia, the small intestine should be investigated. In this case, the procedure of choice is capsule endoscopy. Iron deficiency anemia should always be treated until iron deposits have returned to normal levels. A wide variety of preparations are available, in both oral and parental formulations.
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Baptista V, Marya N, Singh A, Rupawala A, Gondal B, Cave D. Continuing challenges in the diagnosis and management of obscure gastrointestinal bleeding. World J Gastrointest Pathophysiol 2014; 5:523-533. [PMID: 25400996 PMCID: PMC4231517 DOI: 10.4291/wjgp.v5.i4.523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/28/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and management of obscure gastrointestinal bleeding (OGIB) have changed dramatically since the introduction of video capsule endoscopy (VCE) followed by deep enteroscopy and other imaging technologies in the last decade. Significant advances have been made, yet there remains room for improvement in our diagnostic yield and treatment capabilities for recurrent OGIB. In this review, we will summarize the latest technologies for the diagnosis of OGIB, limitations of VCE, technological enhancement in VCE, and different management options for OGIB.
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10
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Saruta M, Papadakis KA. Capsule endoscopy in the evaluation and management of inflammatory bowel disease: a future perspective. Expert Rev Mol Diagn 2014; 9:31-6. [DOI: 10.1586/14737159.9.1.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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11
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Jeong WS, Song HJ, Na SY, Boo SJ, Kim HU, Kim J, Choi GM. Acute extensive ischemic enteritis in a young man diagnosed with wireless capsule endoscopy: a case report. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2013; 61:160-5. [PMID: 23575235 DOI: 10.4166/kjg.2013.61.3.160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Ischemic enteritis is caused by either the interruption or significant reduction of arterial inflow to the small intestine. Risk factors are old age, diabetes mellitus and cardiovascular disease. It is very rare in young patients. We experienced a 21-year-old man with recurrent acute ischemic enteritis who was diagnosed with capsule endoscopy. He had previously taken medications for pulmonary hypertension and obstruction of both carotid arteries, and about 20 months earlier, he had been admitted due to hematochezia. Two sessions of angiography did not reveal the cause of hematochezia. At that time, capsule endoscopy showed mucosal edema and erythema in the terminal ileum, suggesting healed ischemic enteritis. The patient was admitted again due to hematochezia. Abdominal computed tomography showed focal celiac trunk stenosis and diffuse wall thickening of the small intestine, suggesting ischemic enteritis. Capsule endoscopy showed multiple active ulcers and severe hemorrhage with exudate, extending from the proximal jejunum to the terminal ileum. Using capsule endoscopy, the patient was diagnosed with acute extensive ischemic enteritis. Because endoscopic images of ischemic enteritis have rarely been reported, we report a case of a 21-year-old man who was diagnosed acute extensive ischemic enteritis with capsule endoscopy.
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Affiliation(s)
- Woo Seong Jeong
- Departments of Internal Medicine and Radiology, Jeju National University School of Medicine, Jeju, Korea
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Polin V, Coriat R, Perkins G, Dhooge M, Abitbol V, Leblanc S, Prat F, Chaussade S. Iron deficiency: from diagnosis to treatment. Dig Liver Dis 2013; 45:803-9. [PMID: 23582772 DOI: 10.1016/j.dld.2013.02.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 01/26/2013] [Accepted: 02/19/2013] [Indexed: 12/11/2022]
Abstract
Iron deficiency is the most frequent cause of anaemia worldwide. It impairs quality of life, increases asthenia and can lead to clinical worsening of patients. In addition, iron deficiency has a complex mechanism whose pathologic pathway is recently becoming better understood. The discovery of hepcidin has allowed a better clarification of iron metabolism regulation. Furthermore, the ratio of concentration of soluble transferrin receptor to the log of the ferritin level, has been developed as a tool to detect iron deficiency in most situations. The cause of iron deficiency should always be sought because the underlying condition can be serious. This review will summarize the current knowledge regarding diagnostic algorithms for iron deficiency anaemia. The majority of aetiologies occur in the digestive tract, in men and postmenopausal women, and justify morphological examination of the gut. First line investigations are upper gastrointestinal endoscopy and colonoscopy, and when negative, the small bowel should be explored; newer tools such as video capsule endoscopy have also been developed. The treatment of iron deficiency is aetiological if possible and iron supplementation whether in oral or in parenteral form. New parenteral formulations are available and seem to have promising results in terms of efficacy and safety.
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Affiliation(s)
- Vanessa Polin
- Department of Gastroenterology, Cochin Teaching Hospital, AP-HP, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France.
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13
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Soga K, Handa O, Yamada M, Sakagami J, Yagi N, Naito Y, Yoshikawa T, Itoh Y, Arizono N. In vivo imaging of intestinal helminths by capsule endoscopy. Parasitol Int 2013; 63:221-8. [PMID: 24050882 DOI: 10.1016/j.parint.2013.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Revised: 08/29/2013] [Accepted: 09/10/2013] [Indexed: 12/18/2022]
Abstract
This review examines the use of digestive endoscopy to visualize intestinal helminths. The infections caused by these parasites are responsible for high levels of morbidity and mortality. These helminths can be visualized using gastroduodenal endoscopy, endoscopic retrograde cholangiopancreatography, and colonoscopy. Endoscopic examination of the small bowel is limited by its considerable length and its distance from the mouth and anus. Since capsule endoscopy (CE) was first reported in 2000, it has been established as a noninvasive modality for the investigation of the gastrointestinal tract. CE is used as a first-line tool for imaging various small-bowel diseases, mainly obscure gastrointestinal bleeding and Crohn's disease. Since the Food and Drug Administration (FDA) approved CE in 2001, the indications for its use have expanded widely. For example, CE can be used to visualize the in vivo kinetics of intestinal helminths. If the current trends in technological development continue, CE will become more widely used to facilitate the diagnosis and treatment of helminth infections in the near future.
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Affiliation(s)
- Koichi Soga
- Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kyoto 602-8566, Japan; Department of Gastroenterology, Nishijin Hospital, Kyoto 602-8319, Japan.
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14
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Timing of video capsule endoscopy relative to overt obscure GI bleeding: implications from a retrospective study. Gastrointest Endosc 2013; 77:761-6. [PMID: 23375526 DOI: 10.1016/j.gie.2012.11.041] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/29/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Diagnostic yield of video capsule endoscopy (VCE) may be higher if it is performed closer to the time of overt obscure GI bleeding (OOGIB). OBJECTIVE To evaluate the diagnostic yield of VCE and rate of therapeutic intervention for OOGIB for inpatients and outpatients with respect to timing of the intervention. DESIGN Retrospective cohort study. SETTING Tertiary academic center. PATIENTS Patients who had VCE for OOGIB between August 2008 and August 2010. INTERVENTIONS VCE for inpatients versus outpatients. MAIN OUTCOME MEASURES Diagnostic yield and rate of therapeutic intervention for inpatients versus outpatients. RESULTS One hundred forty-four inpatients (65 women) and 116 outpatients (49 women) were included. Diagnostic yield was 65.9% for inpatients versus 53.4% for outpatients (P = .054). Inpatients were divided into those who had VCE within 3 days (<3 days; n = 90) of admission versus after 3 days (>3 days; n = 54). Active bleeding and/or an angioectasia was found in 44.4% of the <3-day group compared with 27.8% of the >3-day group (P = .046) versus 25.8% of the outpatients. Therapeutic intervention was performed in 18.9% of the <3-day group versus 7.4% of the >3-day group (P = .046) versus 10.3% of outpatients. Diagnostic yield and therapeutic intervention rate between the >3-day group and outpatients were not significantly different. Length of stay (days) was less in the <3-day cohort, at 6.1 versus 10.3 in the >3-day cohort (P < .0001). LIMITATIONS Long-term outcomes were not studied. This was a retrospective study. CONCLUSIONS Early deployment of VCE within 3 days of admission results in a higher diagnostic yield and therapeutic intervention rate and an associated reduction of length of stay.
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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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Tennyson CA, Ciaccio EJ, Lewis SK. Video capsule endoscopy in celiac disease. Gastrointest Endosc Clin N Am 2012; 22:747-58. [PMID: 23083991 DOI: 10.1016/j.giec.2012.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Video capsule endoscopy (VCE) provides a safe, non-invasive way to visualize the small intestine and is helpful in celiac disease patients in select situations. VCE can be performed in patients who are unable or unwilling to undergo conventional endoscopy, those with positive celiac serology with normal duodenal biopsies, and also in those who develop alarm symptoms. VCE has limitations including subjective interpretation. Techniques are being developed to standardize assessment of VCE images in patients with known or suspected celiac disease. Pilot studies using computer-based quantification methods have shown promise in examining the 3-dimensional mucosal structure and motility.
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Affiliation(s)
- Christina A Tennyson
- Celiac Disease Center at Columbia University, Division of Digestive Diseases, Columbia University, New York, NY 10032, USA.
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De Palma GD, Masone S, Persico M, Siciliano S, Salvatori F, Maione F, Esposito D, Persico G. Capsule impaction presenting as acute small bowel perforation: a case series. J Med Case Rep 2012; 6:121. [PMID: 22554208 PMCID: PMC3424159 DOI: 10.1186/1752-1947-6-121] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 05/03/2012] [Indexed: 12/22/2022] Open
Abstract
Introduction Perforation caused by capsule endoscopy impaction is extremely rare and, at present, only five cases of perforation from capsule endoscopy impaction are reported in the literature. Case presentation We report here two cases of patients with undiagnosed small bowel stenosis presenting with acute perforation after capsule endoscopy. Strictures in the small bowel were likely the inciting mechanism leading to acute small bowel obstruction and subsequent distension and perforation above the capsule in the area of maximal serosal tension. Case 1 was a 55-year-old Italian woman who underwent capsule endoscopy because of recurrent postprandial cramping pain and iron deficiency anemia, in the setting of negative imaging studies including an abdominal ultrasound, upper endoscopy, colonoscopy and small bowel follow-through radiograph. She developed a symptomatic bowel obstruction approximately 36 hours after ingestion of the capsule. Emergent surgery was performed to remove the capsule, which was impacted at a stenosis due to a previously undiagnosed ileal adenocarcinoma, leading to perforation. Case 2 was a 60-year-old Italian man with recurrent episodes of abdominal pain and diarrhea who underwent capsule endoscopy after conventional modalities, including comprehensive blood and stool studies, computed tomography, an abdominal ultrasound, upper endoscopy, colonoscopy, barium enema and small bowel follow-through, were not diagnostic. Our patient developed abdominal distension, acute periumbilical pain, fever and leukocytosis 20 hours after capsule ingestion. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed ileal Crohn’s stricture, leading to perforation. Conclusions The present report shows that, although the risk of acute complication is very low, the patient should be informed of the risks involved in capsule endoscopy, including the need for emergency surgical exploration.
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Affiliation(s)
- Giovanni D De Palma
- Dipartimento di Chirurgia Generale, Geriatrica ed Endoscopia Diagnostica ed Operativa, Centro di Eccellenza per l'Innovazione Tecnologica in Chirurgia, Università di Napoli Federico II, Medicina e Chirurgia, Naples, Italy.
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Abstract
The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Within the past 10 years, advances have led to an explosion of technologies that facilitate examination of the entire small intestine. Wireless video capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computer tomography (CT) and magnetic resonance (MR) enterography have facilitated the diagnosis, monitoring, and management of patients with small intestinal diseases. These technologies are complementary, each with its advantages and limitations. Capsule endoscopy provides a detailed view of the mucosal surface and has excellent patient acceptance, but does not allow therapeutics. Deep enteroscopy allows careful inspection of the mucosa and therapeutics, but is time consuming and invasive. Enterography (CT or MR) allows examination of the small bowel wall and surrounding structures. The initial best test for detecting small intestinal disease depends on clinical presentation and an astute differential diagnosis.
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Capsule retentions and incomplete capsule endoscopy examinations: an analysis of 2300 examinations. Gastroenterol Res Pract 2011; 2012:518718. [PMID: 21969823 PMCID: PMC3182761 DOI: 10.1155/2012/518718] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 07/19/2011] [Accepted: 07/31/2011] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED Aim. To evaluate capsule endoscopy in terms of incomplete examinations and capsule retentions and to find risk factors for these events. Material and Methods. This retrospective and consecutive study includes data from 2300 capsule enteroscopy examinations, performed at four different hospitals in Stockholm, Sweden from 2003 to 2009. Results. The frequency of incomplete examinations was 20%. Older age, male gender, suspected, and known Crohn's disease were risk factors for an incomplete examination. The PillCam capsule had the highest rate of completed examinations. Capsule retention occurred in 1.3% (n = 31). Risk factors for capsule retention were known Crohn's disease and suspected tumor. Complications of capsule retention were acute obstructive symptoms in six patients and one death related to complications after acute surgical capsule retrieval. CONCLUSION Capsule endoscopy is considered a safe procedure, although obstructive symptoms and serious complications due to capsule retention can be found in a large series of patients.
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Lopes S, Figueiredo P, Portela F, Freire P, Almeida N, Lérias C, Gouveia H, Leitão MC. Capsule endoscopy in inflammatory bowel disease type unclassified and indeterminate colitis serologically negative. Inflamm Bowel Dis 2010; 16:1663-8. [PMID: 20848457 DOI: 10.1002/ibd.21249] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The value of capsule endoscopy in the setting of inflammatory bowel disease type unclassified (IBDU) and indeterminate colitis (IC) remains obscure. The aim was to evaluate the clinical impact of capsule endoscopy on IBDU/IC patients with negative serology. METHODS Eighteen patients with long-standing IBDU (n = 14) and IC (n = 4) were enrolled to undergo a capsule endoscopy and then followed prospectively. Lesions considered diagnostic of Crohn's disease (CD) were 4 or more erosions/ulcers and/or a stricture. The median follow-up time after capsule endoscopy was 32 ± 11 months (23-54 months). RESULTS Total enteroscopy was possible in all patients. In 2 patients the examination was normal (Group 1). In 9 patients subtle findings were observed (Group 2): focal villi denudation (n = 1) and fewer than 4 erosions/ulcers (n = 8). In 7 patients, 4 or more erosions/ulcers were detected (Group 3), leading to a diagnosis of CD. However, their treatment was not reassessed on the basis of the capsule findings. Until now, a definitive diagnosis has been achieved in 2 additional patients: 1 from Group 1 (ulcerative colitis) and another patient from Group 2 (CD), who began infliximab infusions. Nine patients remained indeterminate at follow-up. CONCLUSIONS Although capsule endoscopy enabled the diagnosis of CD in 7 patients, in none of them was the clinical management changed. Moreover, a change in therapy due to a diagnosis of CD was made for only 1 patient, who presented nonspecific findings. Our results suggest that capsule findings are not helpful in the work-up of these patients.
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Affiliation(s)
- Sandra Lopes
- Gastroenterology Department, Coimbra University Hospital, Coimbra, Portugal.
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21
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Ciaccio EJ, Tennyson CA, Lewis SK, Krishnareddy S, Bhagat G, Green PHR. Distinguishing patients with celiac disease by quantitative analysis of videocapsule endoscopy images. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2010; 100:39-48. [PMID: 20356648 DOI: 10.1016/j.cmpb.2010.02.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 01/31/2010] [Accepted: 02/22/2010] [Indexed: 05/29/2023]
Abstract
BACKGROUND Although videocapsule endoscopy images are helpful in the evaluation of celiac disease, their interpretation is subjective. Quantitative disease markers could assist in determining the extent of villous atrophy and response to treatment. METHOD Capsule endoscopy images were acquired from celiac patients with small bowel pathology (N=11) and from control patients (N=10). Image resolution was 576x576 pixels in dimension, 256 grayscale levels, and had a 2 s(-1) frame rate. Pixel brightness and image texture were measured over 10x10 pixel subimages and then averaged for 56x56 subimages per frame. Measurements were obtained at five locations from proximal to distal small intestine in each patient. At each location, measurements were calculated using 200 consecutive image frames (100s). Mean frame-to-frame pixel brightness, image texture, and periodicity in brightness, an estimate of wall motion or intestinal motility, were computed and used for classification with a nonlinear discriminant function. RESULTS From pooled data, celiac images had greater texture than did images from control patients (p<0.001) and exhibited more frame-to-frame brightness variation as well (p=0.032). The dominant period of brightness was longer in celiacs (p=0.001), possibly indicating decreased motility. Using the markers for three-dimensional nonlinear classification of celiacs versus controls, sensitivity was 92.7% and specificity was 93.5%. The relationship between dominant period and small intestinal transit time was approximately linear for both celiacs and controls (r(2)=0.42 and r(2)=0.55, respectively). CONCLUSIONS Videocapsule images can be quantified to detect villous atrophy throughout the small intestine, and to distinguish individuals with celiac disease from individuals lacking mucosal atrophy.
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Affiliation(s)
- Edward J Ciaccio
- Department of Pharmacology, Columbia University College of Physicians and Surgeons, USA
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22
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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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23
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Van Weyenberg SJB, Meijerink MR, Jacobs MAJM, Van der Peet DL, Van Kuijk C, Mulder CJJ, Van Waesberghe JHTM. MR enteroclysis in the diagnosis of small-bowel neoplasms. Radiology 2010; 254:765-73. [PMID: 20177091 DOI: 10.1148/radiol.09090828] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate the diagnostic accuracy and interobserver variance of magnetic resonance (MR) enteroclysis in the diagnosis of small-bowel neoplasms, with small-bowel endoscopy, surgery, histopathologic analysis, and follow-up serving as standards of reference, and to identify MR enteroclysis characteristics capable of enabling discrimination between benign and malignant small-bowel neoplasms. MATERIALS AND METHODS This study was performed in accordance with the guidelines of the institutional review board, and the requirement for informed consent was waived. MR enteroclysis studies of 91 patients (43 women, 48 men; age range, 18-83 years) were retrospectively evaluated by two radiologists blinded to clinical details. Only studies explicitly performed to investigate or exclude the presence of small-bowel neoplasms were included. Radiologic findings were compared with findings of double-balloon endoscopy (n = 45), surgery (n = 18), esophagogastroduodenoscopy (n = 3), ileocolonoscopy (n = 2), autopsy (n = 2), and clinical follow-up for more than 18 months (n = 21). Efficacy parameters were calculated with 95% confidence intervals. Tumor characteristics were compared with the Student t test and the Fisher exact test. RESULTS Readers 1 and 2 interpreted 31 and 33 studies, respectively, as depicting a small-bowel neoplasm and 19 and 17 studies, respectively, as depicting small-bowel malignancy. In 32 patients, the presence of small-bowel neoplasm was confirmed. In 19 of these patients, the neoplasm was malignant. Sensitivity and specificity in the diagnosis of small-bowel neoplasms was 0.91 and 0.95, respectively, for reader 1 and 0.94 and 0.97, respectively, for reader 2; the kappa value was 0.95. Factors associated with malignancy were the presence of longer solitary nonpedunculated lesions, mesenteric fat infiltration, and enlarged mesenteric lymph nodes. CONCLUSION Eighty-six of 91 studies were correctly interpreted, resulting in an overall diagnostic accuracy of 0.95 for MR enteroclysis in the detection of small-bowel neoplasms. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09090828/-/DC1.
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Affiliation(s)
- Stijn J B Van Weyenberg
- Departments of Gastroenterology and Hepatology, Radiology, and Surgery, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands
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Pasha SF, Leighton JA. Enteroscopy in the diagnosis and management of Crohn disease. Gastrointest Endosc Clin N Am 2009; 19:427-44. [PMID: 19647650 DOI: 10.1016/j.giec.2009.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Crohn disease is a chronic disorder that can affect any part of the gastrointestinal tract, and is characterized by mucosal and transmural inflammation of the bowel wall. The disease most commonly involves the small bowel. Evaluation of patients with suspected Crohn disease has traditionally involved the use of ileocolonoscopy, push enteroscopy, and barium small bowel radiography. A large proportion of patients with mild small bowel disease or involvement of the mid small bowel can potentially be missed if only these tests are utilized. Enteroscopy is defined as direct visualization of the small bowel using a fiber optic or wireless endoscope. Following recent advances in technology, enteroscopy currently plays a pivotal role not only in the diagnosis of small bowel Crohn disease but also in the management of its complications, such as bleeding and strictures. Enteroscopy may have additional roles in the future, including the objective assessment of mucosal response to therapy, and surveillance for small bowel malignancy. This article focuses on the utility of enteroscopy, and its advantages and limitations in the evaluation and longterm management of Crohn disease.
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Affiliation(s)
- Shabana F Pasha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ 85259, USA
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Ross WA. Small-bowel imaging: multiple paths to the last frontier. Gastrointest Endosc 2008; 68:1117-21. [PMID: 19028219 DOI: 10.1016/j.gie.2008.04.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 04/28/2008] [Indexed: 12/22/2022]
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Adler DG, Chand B, Conway JD, Diehl DL, Kantsevoy SV, Kwon RS, Mamula P, Rodriguez SA, Shah RJ, Song LMWK, Tierney WM. Capsule endoscopy of the colon. Gastrointest Endosc 2008; 68:621-3. [PMID: 18926174 DOI: 10.1016/j.gie.2008.06.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Accepted: 06/23/2008] [Indexed: 12/13/2022]
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Caprilli R, Angelucci E, Clemente V. Recent advances in the management of Crohn's disease. Dig Liver Dis 2008; 40:709-16. [PMID: 18430617 DOI: 10.1016/j.dld.2008.02.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 02/28/2008] [Indexed: 12/11/2022]
Abstract
In the last 10 years many advances have been achieved in the treatment of patients with Crohn's disease, particularly in the field of biological agents. Infliximab, a tumour necrosis factor alpha antagonist, has been recently added to the therapeutic armamentarium for Crohn's disease and has greatly improved our treatment options. Infliximab has demonstrated efficacy in the induction and maintenance of remission in luminal and fistulizing Crohn's disease both in adults and children. However, the potential development of autoantibodies and the risk of serious adverse events limit the possibility of a wider use of infliximab. Searching for less immunogenicity and higher effectiveness in the last years a number of biological agents have been developed. Adalimumab, a fully human monoclonal antibody anti tumour necrosis factor alpha, has resulted effective and safe in patients with Crohn's disease, both naive and refractory to infliximab, presenting also the advantage of subcutaneous way of administration. Natalizumab also showed promising results in terms of efficacy but its safety is still under investigation. To date no particular advances have been recently appeared in the literature concerning conventional immunosuppressive drugs. Surgery remains a valid resort for refractory patients. Autologous stem cell transplantation represents a new hope as rescue treatment for patients with severe refractory Crohn's disease.
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Affiliation(s)
- R Caprilli
- University of Rome La Sapienza, Rome, Italy.
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Chen X, Zhang ZQ, Zhang Y. Initial experience of capsule endoscopy among healthy individuals. Shijie Huaren Xiaohua Zazhi 2008; 16:2431-2434. [DOI: 10.11569/wcjd.v16.i21.2431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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 assess the practical usefulness and diagnostic yield of capsule endoscopy among healthy individuals.
METHODS: We retrospectively collected and analyzed the clinical data of 114 healthy individuals receiving capsule endoscopy examinations in our hospital from March 2002 to October 2007.
RESULTS: The ratio of successful examination was 99.12% (113/114). Sixty individuals (53.10%) were found with small intestinal diseases of different properties. Forty-three individuals were diagnosed with one kind of small intestinal lesions, 10 with 2 kinds of intestinal lesions, and 7 with 3 kinds of intestinal lesions. Of the 113 individuals, 17 didn't need medical management, 13 needed following up, other examinations or medical interference if necessary, and 30 needed drug interference and following up.
CONCLUSION: Capsule endoscopy can be an alternative modality for diagnosing and screening intestinal diseases, and it is useful for early diagnosis and treatment of small intestinal lesions in asymptomatic people.
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Xu GS, Wu XL, Liu HN. Application of painless endoscopy in the diagnosis and treatment of gastrointestinal diseases. Shijie Huaren Xiaohua Zazhi 2008; 16:1890-1896. [DOI: 10.11569/wcjd.v16.i17.1890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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
Along with the great improvement of life quality, more and more patients prefer painless endoscopy to traditional endoscopy. Most clinical researches have demonstrated the feasibility and safety of painless endoscopy under intravenous anesthesia. By painless endoscopy, doctors are able to give more precise observation of the gastrointestinal tract, make earlier diagnosis of gastric carcinoma, esophagus carcinoma or colon carcinoma. The patients could get more comfortable medical intervention. Various methods are available for intravenous anesthesia in painless endoscopy, such as propofol used alone, or propofol in combination with fentanyl, ketamine or midazolam, etc. All of the painless endoscopy methods have few side effects and can be applied according to specific clinical situations.
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