Recent developments in small bowel endoscopy: the "black box" is now open!

Panenteric capsule endoscopy in gastrointestinal bleeding - time to change old habits?

PURPOSE OF REVIEW

Capsule endoscopy (CE) is an effective tool for small bowel evaluation. Recent technical advancements, including long-lasting batteries and enhanced optics, have enabled featured capsules (panenteric capsules, PCs) to potentially assess the entire gastrointestinal (GI) tract. The PC provides a potential easy-to-use, comprehensive, single-device approach for evaluating GI bleeding patients. This review critically examines the potential role of PC in patients with GI bleeding by highlighting benefits, limitations, open issues, and future challenges.

RECENT FINDINGS

Evidence on PC for GI bleeding patients remains limited. Two retrospective studies and one recent prospective trial consistently show that when used in the workup of GI bleeding patients, PC is safe, feasible, achieves high diagnostic yield (both in the small and large bowel), and potentially reduces the need for unnecessary colonoscopies. Nevertheless, current challenges include the need for extensive bowel preparation, incomplete colon evaluation, and limited access to trained readers.

SUMMARY

The PC holds promise for optimizing the diagnostic workup of GI bleeding patients. However, significant challenges remain. Robust clinical trials comparing standard diagnostic methods to PC-based workup are needed before the adoption of PC in managing bleeding patients in clinical practice.

Small Bowel Tumors: A 7-Year Study in a Tertiary Care Hospital

(1) Background: Tumors of the small bowel represent 3-6% of gastrointestinal neoplasms and 3-6% of GI malignancies. The difficulties regarding the diagnosis are associated with larger tumors at the moment of the diagnosis and with advanced forms of malignant tumors, associated with a dismal prognosis. (2) Methods: We performed an observational, retrospective, cohort study that included patients with small bowel tumors admitted to the Craiova County Emergency Clinic Hospital between 1 January 2017 and 31 December 2023. The data were collected from the analysis of the patient's discharge documents from the Hippocrates computer system of the hospital and the evaluation of endoscopy databases. Patients under 16 years of age, those with no pathological confirmation of the malignancy, and those with insufficient data were excluded. (3) Results: A total of 80 cases of small bowel tumors were diagnosed; 72.5% were malignant, of which 10.3% were metastases. The most frequent primary malignant small bowel tumor was adenocarcinoma; two squamous cell carcinomas were noted. CT scans and upper digestive endoscopy represent the most frequent imaging methods for the diagnosis. The prognosis for malignant tumors was poor, with a 41% 5-year survival rate. (4) Conclusions: Small bowel tumors are rarely encountered, with 72.5% being malignant, and were diagnosed at large dimensions and in advanced stages for malignant tumors, with a dismal prognosis.

Balloon-assisted enteroscopy in the management of adult small-bowel intussusception: a comparative analysis of with and without double-balloon enteroscopy

BACKGROUND

Adult small-bowel intussusception (ASI) is a rare condition with pathological etiologies in most patients. Previously, surgical intervention was the primary treatment modality; however, the introduction of balloon-assisted enteroscopy (BAE) has allowed preoperative BAE in some cases to confirm the leading point, thereby guiding management and reducing surgical need. In this study, we investigated whether the introduction of BAE has altered the diagnostic and therapeutic strategies for ASI by retrospectively analyzing and comparing the clinicopathological features of patients before and after its introduction.

METHODS

Fifty-three patients with ASI, initially diagnosed via abdominal computed tomography scanning at Korea University Guro Hospital from 2000 to 2023, were included in our study. Patients were grouped based on double-balloon enteroscopy (DBE) usage, and clinicopathological outcomes were compared retrospectively.

RESULTS

Of the 53 patients, 38 (71.7%) had enteroenteric-type intussusception and 15 (28.3%) had enterocolic-type intussusception. Among the patients with enteroenteric-type intussusception, 15.8% had a malignant cause, whereas in the enterocolic type, 60% had a malignant cause (p = 0.001). Of 38 patients with enteroenteric ASI, 15 (39.5%) underwent preoperative DBE. The surgical resection rate was significantly lower in the DBE group (40%) than in the non-DBE group (73.9%) (p = 0.037). Pathological diagnoses of patients who underwent surgical resection without preoperative DBE revealed 17.6% malignancies and 82.4% benign causes, including idiopathic intussusception (four cases) and Peutz-Jeghers syndrome (two cases). No morbidity, mortality, or recurrence was observed.

CONCLUSION

Preoperative BAE is a valuable diagnostic and therapeutic modality for ASI, particularly in cases of low-grade small-bowel obstruction, reducing surgical resection rates in most ASI cases. The introduction of the BAE has significantly improved ASI management, achieving high successful reduction rates and few surgical interventions. BAE should be considered a first-line diagnostic and therapeutic tool for ASI management.

Deep learning-based lesion detection and severity grading of small-bowel Crohn's disease ulcers on double-balloon endoscopy images

BACKGROUND AND AIMS

Double-balloon endoscopy (DBE) is widely used in diagnosing small-bowel Crohn's disease (CD). However, CD misdiagnosis frequently occurs if inexperienced endoscopists cannot accurately detect the lesions. The CD evaluation may also be inaccurate owing to the subjectivity of endoscopists. This study aimed to use artificial intelligence (AI) to accurately detect and objectively assess small-bowel CD for more refined disease management.

METHODS

We collected 28,155 small-bowel DBE images from 628 patients from January 2018 to December 2022. Four expert gastroenterologists labeled the images, and at least 2 endoscopists made the final decision with agreement. A state-of-the-art deep learning model, EfficientNet-b5, was trained to detect CD lesions and evaluate CD ulcers. The detection included lesions of ulcer, noninflammatory stenosis, and inflammatory stenosis. Ulcer grading included ulcerated surface, ulcer size, and ulcer depth. A comparison of AI model performance with endoscopists was performed.

RESULTS

The EfficientNet-b5 achieved high accuracies of 96.3% (95% confidence interval [CI], 95.7%-96.7%), 95.7% (95% CI, 95.1%-96.2%), and 96.7% (95% CI, 96.2%-97.2%) for the detection of ulcers, noninflammatory stenosis, and inflammatory stenosis, respectively. In ulcer grading, the EfficientNet-b5 exhibited average accuracies of 87.3% (95% CI, 84.6%-89.6%) for grading the ulcerated surface, 87.8% (95% CI, 85.0%-90.2%) for grading the size of ulcers, and 85.2% (95% CI, 83.2%-87.0%) for ulcer depth assessment.

CONCLUSIONS

The EfficientNet-b5 achieved high accuracy in detecting CD lesions and grading CD ulcers. The AI model can provide expert-level accuracy and objective evaluation of small-bowel CD to optimize the clinical treatment plans.

Outcomes of Double Balloon-Enteroscopy in Elderly vs. Adult Patients: A Retrospective 16-Year Single-Centre Study

Background and Aim: Double-balloon enteroscopy (DBE) is a well-established procedure for direct visualisation of the entire small bowel mucosa, and, in contrast with other imaging techniques, allows to perform biopsies and therapeutic interventions. The aim of this study was to evaluate the indications, diagnostic yield, therapeutic yield, and complications of DBE in a cohort of consecutive patients according to patients’ age. Methods: We conducted a retrospective study of consecutive patients who underwent DBE in our endoscopy unit between January 2006 and December 2021. Results: A total of 387 consecutive patients who underwent 460 DBE procedures were included. Mean age of the patients was 63 years. The overall diagnostic yield was 67.6%; vascular lesions were the predominant endoscopic findings (31.5%), followed by polyps or neoplastic masses (17.6%). Older patients (≥65 years) showed statistically higher rates of clinically relevant findings than adult patients (18–65 years) (p = 0.001). Crohn’s disease and polyps or neoplastic masses were more frequent in the younger group (p = 0.009 and p = 0.066, respectively), while vascular lesions and non-specific inflammation were the most common findings in the older group (p < 0.001 and p < 0.001, respectively). The therapeutic intervention rate was 31.7%. Rates of endoscopic treatment were significantly higher in the older group (p < 0.001). Total complications occurred in five procedures (1.1%). Conclusion: In clinical practice, DBE is an efficient diagnostic and therapeutic tool with a high safety profile, particularly in the elderly population.