Usefulness of capsule endoscopy in patients with suspected small bowel disease

Small bowel malignancy in patients undergoing capsule endoscopy at a tertiary care academic center: Case series and review of the literature

BACKGROUND AND STUDY AIMS

Small bowel cancer is rare, accounting for < 5 % of all gastrointestinal neoplasms. Capsule endoscopy has become the procedure of choice for non-invasive diagnosis of small bowel diseases. Data on capsule endoscopy diagnosis of small bowel cancer are limited. The objective of the study was to determine the frequency, indications and diagnostic work-up of patients with small bowel malignancy found by capsule endoscopy at a Scottish tertiary center.

PATIENTS AND METHODS

In this retrospective study, records all patients who underwent small bowel capsule endoscopy at our center over a 10-year period were reviewed for possible malignancy. Further data were gathered on preceding and subsequent investigations, management and outcome of these patients.

RESULTS

From 1949 studies, small bowel malignancies were diagnosed in only 7 patients (0.36 %; 2F/5M; median age 50, range 34 - 67). The main indication was iron-deficiency anemia (n = 5). Prior to capsule endoscopy, 6 of 7 patients had bidirectional endoscopies and one had gastroscopy. All prior investigations were normal or nondiagnostic. Two of 7 experienced capsule retention. Five of 7 underwent surgery. Four patients died, giving a 5-year survival rate of 42.9 %.

CONCLUSION

 Small bowel malignancies diagnosed by capsule endoscopy are rare, and the median age of 50 indicates they are more common in relatively younger patients. Capsule endoscopy is effective at diagnosing a rare malignancy when other imaging modalities have failed.

Small-bowel capsule endoscopy in patients with unexplained chronic abdominal pain: a systematic review

BACKGROUND

Patients frequently consult primary care physicians and gastroenterologists when experiencing chronic abdominal pain. Although its diagnostic efficacy in these settings is uncertain, small-bowel capsule endoscopy (SBCE) has been used to evaluate the unexplained reasons for abdominal pain.

OBJECTIVE

To evaluate the diagnostic yield of SBCE in patients with unexplained chronic abdominal pain.

DESIGN

We performed a retrospective review of publications reporting the diagnostic yield of SBCE in patients with unexplained chronic abdominal pain and calculated the overall diagnostic yield.

SETTING

Two investigators independently searched studies from databases and analyzed the results.

PATIENTS

A total of 1520 patients from 21 studies were included.

INTERVENTIONS

Small-bowel capsule endoscopy.

MAIN OUTCOME MEASUREMENTS

Per-patient diagnostic yield, with 95% confidence intervals (CI), was evaluated by a random-effect model. Clear categorical analysis also was performed.

RESULTS

The pooled diagnostic yield of SBCE in patients with unexplained chronic abdominal pain was 20.9% (95% CI, 15.9%-25.9%), with high heterogeneity (I(2) = 80.0%; P ＜ .001). Inflammatory lesions were the most common (78.3%) positive findings, followed by tumors (9.0%).

LIMITATIONS

Heterogeneity among studies, retrospective design, variable chronicity of abdominal pain, and different previous examinations before SBCE.

CONCLUSION

SBCE provides a noninvasive diagnostic tool for patients with unexplained chronic abdominal pain, but the diagnostic yield is limited (20.9%). Among patients with positive findings, inflammatory lesions are the most common.

Application of colon capsule endoscopy (CCE) to evaluate the whole gastrointestinal tract: a comparative study of single-camera and dual-camera analysis

Background and study aims

Colon capsule endoscopy (CCE) was developed for the evaluation of colorectal pathology. In this study, our aim was to assess if a dual-camera analysis using CCE allows better evaluation of the whole gastrointestinal (GI) tract compared to a single-camera analysis.

Patients and methods

We included 21 patients (12 males, mean age 56.20 years) submitted for a CCE examination. After standard colon preparation, the colon capsule endoscope (PillCam Colon™) was swallowed after reinitiation from its “sleep” mode. Four physicians performed the analysis: two reviewed both video streams at the same time (dual-camera analysis); one analyzed images from one side of the device (“camera 1”); and the other reviewed the opposite side (“camera 2”). We compared numbers of findings from different parts of the entire GI tract and level of agreement among reviewers.

Results

A complete evaluation of the GI tract was possible in all patients. Dual-camera analysis provided 16% and 5% more findings compared to camera 1 and camera 2 analysis, respectively. Overall agreement was 62.7% (kappa = 0.44, 95% CI: 0.373–0.510). Esophageal (kappa = 0.611) and colorectal (kappa = 0.595) findings had a good level of agreement, while small bowel (kappa = 0.405) showed moderate agreement.

Conclusion

The use of dual-camera analysis with CCE for the evaluation of the GI tract is feasible and detects more abnormalities when compared with single-camera analysis.

Patency© and agile© capsules

Small bowel strictures can be missed by current diagnostic methods. The Patency capsule is a new non-endoscopic dissolvable capsule which has as an objective of checking the patency of digestive tract, in a non-invasive manner. The available clinical trials have demonstrated that the Patency^© capsule is a good tool for assessment of the functional patency of the small bowel, and it allows identification of those patients who can safely undergo a capsule endoscopy, despite clinical and radiographic evidence of small-bowel obstruction. Some cases of intestinal occlusion have been reported with the Patency^© capsule, four of them needed surgery. So, a new capsule with two timer plugs (Agile^© capsule) has been recently developed in order to minimize the risk of occlusion. This new device stars its dissolution process earlier (30 h after ingestion) and its two timer plugs have been designed to begin the disintegration even when the device is blocked in a tight stricture.

The utility of capsule endoscopy in the diagnosis of Crohn's disease based on patient's symptoms

BACKGROUND AND GOALS

Video capsule endoscopy (VCE) enables visualization of the entire small bowel and can identify lesions that may go undetected by conventional endoscopy and radiography. In this study, we assessed whether patient's selection based on symptoms may increase the yield of VCE in the diagnosis of Crohn's disease (CD).

STUDY

Findings of 125 consecutive patients referred for VCE in whom CD may be suspected, were analyzed. Indications for VCE included iron-deficiency anemia, abdominal pain, diarrhea, or a combination of symptoms. Capsule endoscopy (CE) results were defined positive if 4 or more obvious clear ulcers, erosions, or a region with clear exudate and mucosal hyperemia and edema were identified.

RESULTS

One hundred twelve patients were included in the final analysis. Mean age of patients was 44+/-22 years and median follow-up 36+/-15 months. Findings on CE were considered compatible with a diagnosis of CD in 7 patients (6%). In general, CE yielded a diagnosis of CD in a very small portion of the patients (0% to 4%), except in patients undergoing the test for a combination of abdominal pain and diarrhea. In this group, findings suggestive of inflammatory bowel disease were encountered in one-third of the patients (P=0.002).

CONCLUSIONS

The greatest yield of CE in diagnosing CD is achieved in young patients who present with symptoms of abdominal pain plus diarrhea.

Role of capsule endoscopy in inflammatory bowel disease: where we are and where we are going

Capsule endoscopy (CE) is an innovative technological breakthrough that for the first time provides a noninvasive method to obtain high-resolution imaging of the entire small bowel. Since its recent inception, the diagnostic utility of CE has become well established for the evaluation of diverse ulcerative and inflammatory disorders of the jejunum and ileum. The incredible resolution of its lens (0.1 mm) detects focal villous edema or atrophy, denuded, as well as ulcerated mucosal lesions missed by other imaging techniques. CE has been shown by meta-analysis to be a more sensitive method to investigate patients for small bowel Crohn's disease, with an incremental yield above 30% versus other imaging modalities. In patients with indeterminate colitis, CE is useful in distinguishing between ulcerative and Crohn's colitis. Among patients with established Crohn's disease, CE may be employed to determine: (1) the extent and severity of small bowel involvement, (2) postoperative recurrence, (3) post-therapy mucosal healing, and (4) whether active small bowel inflammatory lesions exist in the clinical setting of functional bowel disorder. Complications are rare and include capsule retention at stricture sites. The new patency capsule can diminish the risk of the latter problem in at-risk patients. CE can also serve as a guide to sites that require biopsies or dilatation by push or double-balloon enteroscopy. However, other causes of small bowel lesions may mimic Crohn's disease. A standard terminology system has thus been developed, and a CE Crohn's disease severity scoring index is currently undergoing validation studies.

Bleeding update

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

Meta-analysis: capsule enteroscopy vs. conventional modalities in diagnosis of small bowel diseases

BACKGROUND

Prospective trials support the role of capsule enteroscopy as an improvement in diagnosing mucosal lesions in the small bowel.

AIM

To determine the diagnostic yield and safety of capsule enteroscopy vs. alternative diagnostic modalities (such as push enteroscopy, small bowel follow-through or enteroclysis) in patients with small bowel diseases.

METHODS

A search for prospective studies comparing capsule enteroscopy vs. other diagnostic tests in adults was performed between 1966 and 2005. Selected articles were included in a meta-analysis. Three analyses were run separately, all included studies and studies having occult gastrointestinal bleeding or Crohn's disease as main outcome.

RESULTS

Seventeen studies (526 patients) met inclusion criteria. The rate difference (i.e. the absolute pooled difference in the rate of positive findings) between capsule enteroscopy and alternative modalities for small bowel disease was 41% (95% CI 35.6-45.9); 37% (95% CI 29.6-44.1) for occult gastrointestinal bleeding; and 45% (95% CI 30.9-58.0) for Crohn's disease. Failure to visualize the caecum occurred in 13%, significantly more often in occult bleeders (17%) than in patients with Crohn's disease (8%) (P < 0.006). Adverse events were recorded in 29 patients (6%). Capsule retention was more frequent in patients with Crohn's disease (3% vs. 1%, OR 4.37).

CONCLUSIONS

Capsule enteroscopy proved significantly superior to push enteroscopy and small bowel radiology in the diagnosis of ileal diseases. Capsule enteroscopy is safe, though prior radiology is still necessary to rule out small bowel strictures in patients with known or suspected Crohn's disease.