Multicenter prospective registration study of efficacy and safety of capsule endoscopy in Crohn's disease in Japan (SPREAD-J study)

BACKGROUND

Evidence of small-bowel capsule endoscopy (SBCE) for evaluating lesions in Crohn's disease (CD) is lacking. We aimed to clarify the effectiveness and safety of SBCE in a large sample of patients with CD.

METHODS

This multicenter prospective registration study recorded the clinical information and SBCE results of patients with definitive CD (d-CD) or suspected CD (s-CD). The primary outcomes were the rates of successful assessment of disease activity using SBCE, definitive diagnosis of CD, and adverse events. Secondary outcomes were the assessment of SBCE findings in patients with d-CD and s-CD and factors affecting SBCE incompletion and retention; and tertiary outcomes included the association between clinical disease activity or blood examination, endoscopic disease activity, ileal CD, and the questionnaire assessment of patient acceptance of SBCE.

RESULTS

Of 544 patients analyzed, 541 underwent SBCE with 7 (1.3%) retention cases. Of 468 patients with d-CD, 97.6% could be evaluated for endoscopic activity. Of 76 patients with s-CD, 15.8% were diagnosed with 'confirmed CD'. CD lesions were more frequently observed in the ileum and were only seen in the jejunum in 3.4% of the patients. Male sex and stenosis were risk factors for incomplete SBCE, and high C-reactive protein levels and stenosis were risk factors for capsule retention. In L1 (Montreal classification) patients, clinical remission was associated with endoscopic remission but showed low specificity and accuracy. The answers to the acceptability questionnaire showed the minimal invasiveness and tolerability of SBCE.

CONCLUSION

SBCE is practical and safe in patients with CD.

Updates in the diagnosis and management of small-bowel tumors

Small-bowel tumors represent a rare entity comprising 0.6% of all new cancer cases in the US, and only 3% of all gastrointestinal neoplasms. They are a heterogenous group of neoplasms comprising of about forty different histological subtypes with the most common being adenocarcinoma, neuroendocrine tumors, stromal tumors and lymphomas. Their incidence has been reportedly increasing over recent years, partly owing to the advances and developments in the diagnostic modalities. Small-bowel capsule endoscopy, device assisted enteroscopy and dedicated small-bowel cross-sectional imaging are complimentary tools, supplementing each other in the diagnostic process. Therapeutic management of small-bowel tumors largely depends on the histological type and staging at diagnosis. The aim of the present review article is to discuss relevant advances in the diagnosis and management of small-bowel tumors.

Safety and efficacy of small-bowel capsule endoscopy examination in patients with Billroth II gastrojejunostomy

BACKGROUND

Small-bowel capsule endoscopy (SBCE) has become an increasingly utilized imaging modality for patients suspected of having small intestinal diseases. However, data regarding the role of SBCE in patients with Billroth II gastrojejunostomy are limited. The objective is to evaluate the safety and efficacy of SBCE in Billroth II gastrojejunostomy patients.

METHODS

We retrospectively studied patients with Billroth II gastrojejunostomy who underwent MiroCam capsule endoscopy between August 2013 and October 2019. Baseline patient characteristics; gastroscopic and SBCE findings; capsule transit time; and the occurrence of adverse events were collected and compared between groups with and without anastomotic lesions.

RESULTS

In total, 30 patients were analyzed in the study. The median age was 59 years, and 26 patients (86.7%) were men. The majority of SBCE positive findings including ulcers (10.0%), angioectasias (6.7%) and polyps (6.7%). In patients with (n = 10) and without (n = 20) anastomotic lesions, the anastomotic lesion was significantly associated with a delayed gastric transit time (GTT) (P = 0.026), but the two groups showed no significant difference in completion (P > 0.05). All patients underwent successful SBCE examinations without adverse events, except device transit into the afferent loop, where it remained for nearly 2 h, occurred in one case with anastomotic ulcers.

CONCLUSIONS

This retrospective study demonstrates that SBCE is a safe and effective diagnostic tool in patients with Billroth II gastrojejunostomy with a favorable gastroscopic evaluation within 7 days prior. The frequently real-time monitoring is suggested due to the risk of retention in the afferent loop, and a delayed food intake is required when a prolonged stay in the afferent loop occurred.

Capsule endoscopy - Recent developments and future directions

INTRODUCTION

Capsule endoscopy (CE) is an established modality in the diagnostic algorithm of small bowel (SB) pathology. Its use has expanded for investigation of upper and lower gastrointestinal diseases with similar prototypes.

AREAS COVERED

This review covers the role and recent advances of CE, as a non-invasive investigative tool.

EXPERT OPINION

The use of upper gastrointestinal CE is useful in patients who require surveillance for varices particularly in the current era of the COVID-19 pandemic. It has also shown high accuracy in the detection of upper gastrointestinal hemorrhage in patients presenting with a suspicion of hemorrhage. Findings on CE help to guide further management by device-assisted enteroscopy. The data on colon CE suggest comparable diagnostic accuracy to colonoscopy for polyp detection; however, more evidence is required in the high-risk group. Crohn's CE has become an integral part of the management of patients with Crohn's disease offering a comparative assessment tool post escalation of therapy. Artificial intelligence within CE has demonstrated similar if not better diagnostic yield compared to the human with a significantly shorter reading time. Artificial intelligence is likely to be in-built within CE reading platforms over the next few years minimizing reporting time and human error.

Indications and diagnostic yield of small-bowel capsule endoscopy in a real-world setting

Background

Indications and diagnostic yield of small-bowel video capsule endoscopy (SB-VCE) are communicated in recent clinical academic guidelines. However, guidelines are based mainly on relatively few, small, selection-biased studies at experienced centers, and thus we lack information on indications and diagnostic yield of SB-VCE in the real-world community setting. The aim of the study was to evaluate indications and diagnostic yield of SB-VCE in the real-world community setting.

Methods

Our local VCE clinical database was used to identify patients undergoing SB-VCE procedures over a 7-year period (2011–2018). Patients were broadly referred and underwent SB-VCE using PillCam™ SB 2 and SB 3 capsule systems. Procedures were reviewed by local endoscopists, who had undergone similar formal SB-VCE review training. Medical reports of the procedures were composed as such. We retrospectively reviewed all reports and gathered data regarding indications and findings. Diagnostic yield was considered positive if SB-VCE visualized any type of clinically significant pathological finding.

Results

536 SB-VCE procedures in 516 patients were included in final assessment. Patient mean (± SD) age was 50 ± 20 years with approximately even female/male ratio (275:241). The overall proportion of positive findings was 42% (225/536). The two main indications were obscure gastrointestinal bleeding (occult/anemia or overt/active, OGIB) of 46% (246/536) and definite/suspected Crohn’s disease (CD) of 39% (210/536). Positive SB-VCE findings were obtained in 44% (108/246) of procedures with indication of OGIB and in 50% (104/210) of procedures with indication of CD.

Conclusions

The indications for SB-VCE are largely consistent with guidelines but with an apparently relatively low diagnostic yield in our real-world community setting.

Recurrent Gastrointestinal Bleeding from Dieulafoy's Lesions in a Patient with Type 1 von Willebrand Disease: A Rare Association

Von Willebrand disease (vWD) is the most prevalent hereditary bleeding disorder, affecting 0.6-1.3% of the population. While gastrointestinal bleeding from angiodysplasia is a well-known complication of vWD, the same is not true for Dieulafoy's lesions (DLs). We report the case of a 21-year-old black male with type 1 vWD and 2 previous hospital admissions for severe anemia with no visible blood loss. In both episodes, DLs were identified and treated endoscopically, one in the stomach and another in the duodenum. The patient presented to the emergency department in September 2016 with dizziness, fatigue, and again no visible blood loss. He was hemodynamically stable, and laboratory workup showed a hemoglobin level of 3.4 g/dL. After transfusion of packed red blood cells, intravenous iron, and von Willebrand factor/factor VIII concentrate infusions, the patient underwent upper endoscopy and colonoscopy, which were normal. Small-bowel capsule endoscopy showed dark blood and a fresh clot in the proximal jejunum. At this site, push enteroscopy identified a pulsatile vessel with an overlying minimal mucosal defect, consistent with a DL, type 2b of the Yano-Yamamoto classification, which was successfully treated with adrenaline and 2 hemoclips. The patient remains stable after 18 months of follow-up, with a hemoglobin level of 13.2 g/dL. This is a case of recurrent severe occult gastrointestinal bleeding from multiple DL in a young patient with vWD who is otherwise healthy. Three other cases of DL bleeding in the setting of vWD have been reported in the literature, suggesting a possible association between these 2 entities.

Small-Bowel Capsule Endoscopy in Clinical Practice: Has Anything Changed Over 13 Years?

BACKGROUND

In Lombardia, one of the 20 Italian administrative Regions, small-bowel capsule endoscopy (SBCE) was introduced in 2001. In January 2011, the Regional Health Authorities established a reimbursement for outpatient SBCE.

AIM

To prospectively record data on SBCE between 2011-2013 and compare them to similar data retrospectively collected from the same geographical area (covering the period 2001-2008) and published in 2008.

METHODS

Consecutive SBCEs performed between January 2011 and December 2013 in Lombardia were prospectively collected.

RESULTS

In 3 years, 3142 SBCEs were collected; the diagnostic yield (DY) and the overall complication rate were 48.4 and 0.9%, respectively. The main indication was suspected small-bowel bleeding (76.6% of patients); complete small-bowel inspection was achieved in 2796 (89.0%) patients. SBCE was performed as an outpatient procedure in 1945 patients (61.9%). A significant increase in the rate of patients undergoing SBCE for suspected small-bowel bleeding was observed from 2001-2008 to 2011-2013 (67.3 vs. 76.1%; p < 0.001). There was an increase in the number of complete small-bowel examinations (81.2 vs. 89.0%; p < 0.001) and of outpatient SBCEs (6.7 vs. 61.9%; p < 0.001). Conversely, both the retention rate (2.1 vs. 0.8%; p < 0.001) and the rate of patients undergoing SBCE for Crohn's disease (11.5 vs. 5.5%; p < 0.001) decreased significantly. The overall DY remained stable (50.6 vs. 48.4%; p = 0.089).

CONCLUSION

Our study shows that, over 13 years, the SBCE safety profile and completion rate significantly improved over time; a change in the spectrum of clinical indications was also observed.

Advanced endoscopic imaging techniques in Crohn's disease

BACKGROUND

Endoscopy is of pivotal importance in Crohn's disease (CD) patients for diagnosis, surveillance and assessment of disease activity and extent. Device-assisted enteroscopy (DAE) and small-bowel capsule endoscopy (SBCE) have recently changed our endoscopic approach to small-bowel imaging. Furthermore, new advanced endoscopic imaging techniques have been implemented into clinical practice to improve both characterization of mucosal inflammation and detection of dysplastic lesions.

AIM

To provide readers with a review about the concept of advanced endoscopic imaging for the diagnosis and characterization of CD.

METHODS

A literature search on the use of advanced endoscopy techniques in IBD patients was performed.

RESULTS

DAE and SBCE allow for deep enteroscopy with high diagnostic yields and low complication's rate but their collocation in the diagnostic algorithm is still not clearly defined. Dye-based chromoendoscopy (DBC) and magnification chromoendoscopy improved dysplasia's detection in long standing colitis and prediction of inflammatory activity and extent. Dye-less chromoendoscopy (DLC) might offer the potential to replace conventional DBC for surveillance. However, both narrow band imaging and i-scan have already shown to significantly improve activity and extent assessment in comparison to white-light endoscopy. Confocal laser endomicroscopy (CLE) can detect more dysplastic lesions in surveillance colonoscopy and predict neoplastic and inflammatory changes with high accuracy compared to histology. Moreover, CLE-based molecular imaging may anticipate the therapeutic responses to biological therapy. Endocytoscopy can identify in vivo inflammatory mucosal cells harboring a new method to assess the mucosal activity.

CONCLUSIONS

Recent progresses in small-bowel enteroscopy offer several potential benefits to improve both diagnosis and characterization of CD. New advanced endoscopic imaging techniques can improve detection of dysplasia and refine mucosal healing assessment, even looking beyond the morphological parameters revealed by conventional endoscopic imaging.

Two cameras detect more lesions in the small-bowel than one

AIM: To explore the feasibility of dual camera capsule (DCC) small-bowel (SB) imaging and to examine if two cameras complement each other to detect more SB lesions.

METHODS: Forty-one eligible, consecutive patients underwent DCC SB imaging. Two experienced investigators examined the videos and compared the total number of detected lesions to the number of lesions detected by each camera separately. Examination tolerability was assessed using a questionnaire.

RESULTS: One patient was excluded. DCC cameras detected 68 positive findings (POS) in 20 (50%) cases. Fifty of them were detected by the “yellow” camera, 48 by the “green” and 28 by both cameras; 44% (n = 22) of the “yellow” camera’s POS were not detected by the “green” camera and 42% (n = 20) of the “green” camera’s POS were not detected by the “yellow” camera. In two cases, only one camera detected significant findings. All participants had 216 findings of unknown significance (FUS). The “yellow”, “green” and both cameras detected 171, 161, and 116 FUS, respectively; 32% (n = 55) of the “yellow” camera’s FUS were not detected by the “green” camera and 28% (n = 45) of the “green” camera’s FUS were not detected by the “yellow” camera. There were no complications related to the examination, and 97.6% of the patients would repeat the examination, if necessary.

CONCLUSION: DCC SB examination is feasible and well tolerated. The two cameras complement each other to detect more SB lesions.