The role of capsule endoscopy combined with double-balloon enteroscopy in diagnosis of small bowel diseases

Background The diagnosis of small bowel diseases remains relatively inefficient using traditional imaging techniques. Capsule endoscopy （CE） and double-balloon enteroscopy （DBE） are two novel methods of enteroscopy for examining the entire small bowel. The aim of this study was to evaluate the detection rate and diagnostic accuracy of CE and DBE in patients with suspected small bowel diseases and to investigate the clinical significance of combined use of these two novel modalities. Methods Two hundred and eighteen patients were evaluated for suspected small bowel disease, including 116 with obscure gastrointestinal bleeding and 102 with obscure abdominal pain or chronic diarrhea. One hundred and sixty-five out of these patients underwent CE first and 53 patients underwent DBE （under anesthesia with propofol） first. DBE was recommended after negative or equivocal evaluation on CE and vise versa. Introduction of the endoscope during DBE was either orally or anally and the patients were referred for a second procedure using the opposite route several days later when no abnormalities were found on the first procedure. The detection rates, diagnostic accuracy, tolerance and frequency of adverse events of these two modalities were then analyzed. Results Failure of the procedure was seen in one patient with CE and in two patients with DBE. Sixty-four DBE procedures were carded out in 51 patients; by the oral route in 34 cases, the anal route in 4 and both routes in 13 cases. The overall detection rate of small bowel diseases using CE （72.0%, 118/164） was superior to that with DBE （41.2%, 21/51）; X2=16.1218, P〈0.0001. The diagnostic rate （51.8%, 85/164） was also higher than that with the latter procedure （39.2%, 20/51）, but was not significantly different （X^2=2.4771, P〉0.05）. Furthermore, the detection rate of small bowel diseases in patients with obscure gastrointestinal bleeding using CE （88.0%, 88/100） was superior to that of DBE （60.0%, 9/15）; X2=7.7457, P=0.0054. Lesions were detected by DBE in 1 out of 4 patients in whom CE had a negative result. Suspected findings by CE were confirmed by DBE combined with biopsy in 12 out of 15 patients. On the other hand, small bowel lesions were identified by CE in all 3 patients after negative evaluations by DBE. There were no severe complications during or after either of the two procedures. Conclusions The detection rate of small bowel diseases by CE is very high. CE should be selected for the initial diagnosis in patients with suspected small bowel diseases, especially in patients with obscure gastrointestinal bleeding. DBE appears to be inferior to CE in the diagnosis of small bowel diseases. However, it was shown that abnormalities could still be identified by DBE in patients with normal images or used to confirm suspected findings from CE. DBE can also serve as a good complementary approach after an initial diagnostic imaging using CE.     

Small bowel diseases discovered by computed tomography enterography but omitted by small bowel endoscopy

To the editor:We found two small bowel diseases discovered by computed tomography enterography (CTE) and omitted by small bowel endoscopy.The two patients were both found obscure gastrointestinal bleeding in our hospital.One was found a small bowel stromal tumor,CTE findings mainly characterized by congested tumor without obstruction,with calcification spots in the tumor,and with obvious thickening of the feeding artery and draining vein and obvious edema of the intestinal wall (Figure 1A).Another was an arterial-venous malformation,CTE showing abnormal thickening of vessels in the intestinal wall in the arterial phase (Figure 1B).The lesions of these two cases were in the bordering parts of the jejunoileum.     

Updates and Future of Enteroscopy

Video capsule emdoscopy （VCE） and double balloon endoscopy （DBE） have allowed endoscopic observation of the entire small bowel. With introduction of these modalities, we have identified new diseases of the small bowel. Although VCE has a safe ability to check the entire small bowel, VCE is inhibited in patients with stenosis induced by Crohn＇s disease or non-steroidal anti-inflammatory drugs.In contrast,     

Application of double-balloon enteroscopy in the diagnosis and therapy of small intestinal diseases

Background X-ray of the digestive tract and radionuclide examination could not accurately detect diseases of the small intestine. Double-balloon enteroscopy has been used to increase the detection rate of these diseases in addition to endoscopic biopsy and therapy. The purpose of this study was to determine the value of double-balloon enteroscopy in the diagnosis and treatment of diseases of the small intestine. Methods A total of 258 double-balloon enteroscopies via the mouth and/or anus were performed in 208 patients. If no lesion was detected on one side （mouth or anus）, examination on the other side （anus or mouth） was made. If active small intestinal bleeding was detected, endoscopic hemostasis was done to treat the bleeding. Results In the 208 patients, 50 were subjected to double-balloon enteroscopy via both mouth and anus. Lesions were detected in 151 patients, giving a rate of 72.6% （151/208）. The detection rates for obscure digestive tract bleeding, diarrhea, abdominal pain and weight loss were 90.2% （92/102）, 64.9% （24/37）, 48.5% （16/33） and 43.3% （13/30）, respectively. Lesions of the 151 patients were confirmed by endoscopic biopsy, surgery, clinical studies, and follow-up. In the 102 patients with bleeding of the digestive tract, active bleeding was detected in 27 patients. Endoscopic hemostasis was successful in 25 of them （92.6%, 25/27）. No serious complications occurred in all the patients, the average time for the procedure was 100 minutes. Conclusions Double-balloon enteroscopy is safe, effective in the diagnosis of diseases of the small intestine in addition to endoscopic therapy.     

Pharmacokinetics of aminophylline delivered to the small intestine and colon using remote controlled capsules

Background A patented remote controlled capsule （RCC） has recently been developed to provide noninvasive drug delivery to selected sites in the human gut that allows assessment of regional gastrointestinal （GI） drug absorption under a normal physiological environment. The objective of this study was to investigate the rate and extent of aminophylline absorption after site-specific delivery of the drug in the GI tract using RCC and a magnetic marker monitoring （MMM） technique. Methods This study was conducted in twelve healthy male subjects, in a three-treatment, randomized, crossover manner with a 7-day washout. Eligible subjects received a 150 mg aminophylline dose through an oral administration, or via a remote controlled capsule, delivered to the small bowel or ascending colon. MMM was employed to monitor the GI transit of the RCC, and the radio-frequency signal was used to activate capsules at target sites. Blood samples were obtained at regular intervals until 24 hours post dose/activation. Plasma theophylline concentrations were measured by a TDx~ System Analyzer. A comparison of the PK profile with the oral dosing route of aminophylline was performed after delivery to the small bowel and colon. Results The RCC was well tolerated in volunteers. The mean capsule activation time for the small bowel and ascending colon was 2.07 hours and 6.08 hours post dose. Aminophylline had similar absorption profiles from the small bowel compared with the stomach, with an area under the curve （AUCt） ratio of 92% vs. the stomach, but a lower absorption profile from the ascending colon, with an AUCt ratio of 47.2% vs. the stomach. Conclusions The proprietary of the RCC and MMM technique offer the opportunity to obtain data on the intestinal absorption of a drug in humans under noninvasive conditions. Aminophylline is rapidly and efficiently absorbed from the small bowel. While colonic absorption was limited by the poor water condition although effective absorption was observed from the ascending colon. This provides an opportunity for rational development of modified-release formulations as well as alternative dosage forms.     

Clinical value of sequential subtraction scintigraphy with 99m Tc-RBC for gastrointestinal bleeding

Objective　To evaluate the clinical value of sequential subtraction scintigraphy (SSS) with 99mTc red blood cell (RBC) for the early detection of gastrointestinal (GI) bleeding. Methods　Ninety patients referred with clinical evidence of GI bleeding underwent 99m　Tc-RBC scintigraphy with digital gamma camera after labeling of 99m　 Tc-RBC in vivo. Sequential 12 conventional non-subtraction (CNS) images of abdomen were taken at 5 min intervals for 60 min. Then 5-min images were subsequently subtracted from each other using a computer and 11 subtracted images were obtained. Delayed images up to 24 hr were obtained when early results were negative and/or recurrent bleeding was suspected. Results　62 of 90 patients with suspected GI bleeding were conformed to have active hemorrhage up to 24 hr. The scintigrams were divided into the following three sets: within 30 min, 60 min, and 24 hr. The sensitivity of SSS was 87% (54/62, 30?min) and 91.9% (57/62, 60 min) respectively, which were significantly higher (P<0.05) than that of CNS (56.4%, 35/62 and 62.9%, 39/62). 24 hr delayed image of CNS increased the sensitivity to 85.4%. No significant difference in specificity between the two methods was noted. Of the 62 patients with definite active hemorrhage, the bleeding sites were identified by surgical operation in 42. The concordant rate with surgical operation in SSS was 92.8% (39/42), higher than that of CNS (73.8%, 31/42). Conclusions　Sequential subtraction scintigraphy with 99m　 Tc-RBC, compared with conventional non-subtraction scintigraphy, is an effective technique for the early detection of GI bleeding. It increases the diagnostic sensitivity, detecting a small amount of bleeding earlier than CNS; SSS reduces background activity, more accurately localizing bleeding sites. It also shortens the examination time, making this approach more suitable for pediatric, elderly and critically ill patients.     

Updates and Future of Enteroscopy

Video capsule emdoscopy (VCE) and double balloon endoscopy (DBE) have allowed endoscopic observation of the entire small bowel. With introduction of these modalities, we have identi ed new diseases of the small bowel. Although VCE has a safe ability to check the     

Unsedated versus sedated gastrointestinal endoscopy: A questionnaire investigation in Wuhan, central China

National data show that in China mainland unsedated gastrointestinal （GI） endoscopy has been applied in most hospitals for clinical examination, while sedated GI endoscopy is only performed in some hospitals. The purpose of this study was to compare sedated versus unsedated GI endoscopy regarding cost, safety, degree of comfort, tolerance level and overall satisfaction of patients over a 6-month period investigation. From March to September 2011, a questionnaire survey was performed on 1800 patients and 30 physicians at Zhongnan Hospital of Wuhan University and Wuhan General Hospital of Guangzhou Military Command. The patients fell into two groups according to their own de- cisions： the unsedated group （n=1000） and the sedated group （n=800）. After examination, the patients and the physicians were required to fill in a questionnaire form. All the data were analyzed statistically. The results showed that the main factors the patients took for consideration between sedated and unse- dated procedures included economy, comfort and safety. The income levels between the sedated and unsedated groups showed significant difference （P〈0.01）. Most patients in the unsedated group had lower income and were covered by less medical insurance. The tolerance rate was 92.4% vs. 65.5% be- tween the sedated and unsedated group, respectively. 95.5% patients in the sedated group and 72.1% pa- tients in the unsedated group chose the same endoscopy procedure for repeat examination. The survey data from endoscopists suggested the sedated procedure was more comfortable but less safe than the unsedated procedure （P〈0.01 ）. In China, unsedated GI endoscopy is now widely accepted by the major- ity of patients due to low cost and safety. Compared to unsedated GI endoscopy, sedated GI endoscopy is less painful, but more expensive and less safe. With the rapid improvement of people＇s living stan- dard and the reliability of sedation technology, we expect sedated GI endoscopy will be gradually ac- cepted by more patients.     

Relationship between chronic diarrhea with normal colonoscopy findings and terminal ileum lesions

Background The causes and mechanisms of chronic diarrhea are complex.This study aimed to explore the relationship between chronic diarrhea with normal colonoscopy findings and terminal ileum lesions.Methods All cases were collected from January 2009 to June 2010.The 40 patients in the patient group had chronic diarrhea with normal colonoscopy findings.Those who had hyperthyroidism,diabetes,chronic pancreatitis,cirrhosis,atrophic gastritis,short bowel syndrome and connective tissue diseases had been excluded.The control group contained 40 healthy individuals without diarrhea.Endoscopy of the terminal ileum was applied in both groups,with the endoscope inserted into terminal ileum for more than 20 cm.The patients diagnosed of chronic diarrhea with terminal ileum lesions were treated with metronidazole and probiotics for 10-14 days.Results Before treatment there were significant differences in endoscopy findings of the terminal ileum between the two groups （P 〈0.05）.In the patient group,endoscopy showed congestion,edema,erosion and ulcers in 29 cases,hyperplasia and enlargement of lymphoid follicles in 10 cases with a maximal diameter of 7-8 mm,and 1 case showed normal endoscopy results.After treatment,35 patients recovered from diarrhea,and terminal ileum lesions disappeared in 30 cases as determined by endoscopy.In the control group,endoscopy showed scattered hyperplasia of lymphoid follicles in 5 cases,and the follicles were small with the maximal diameter being 3 mm.There was no hyperemia,edema,erosion or ulcers.Conclusions Chronic diarrhea patients with normal colonoscopy findings may have lesions in the terminal ileum that can be detected by endoscopy; including hyperemia,erosion,ulcers and lymphoid follicle hyperplasia.Therapeutic effect is good with metronidazole and probiotics.     

CT结肠成像联合计算机辅助检测在结肠息肉诊断价值初探

Background  Colonic polyps are frequently encountered in clinics. Computed tomographic colonography (CTC), as a painless and quick detection, has high values in clinics. In this study, we evaluated the application value of computer-aided detection (CAD) in CTC detection of colonic polyps in the Chinese population.

Methods  CTC was performed with a GE 64-row multidetector computed tomography (MDCT) scanner. Data of 50 CTC patients (39 patients positive for at least one polyp of ≥0.5 cm in size and the other 11 patients negative by endoscopic detection) were retrospectively reviewed first without computer-aided detection (CAD) and then with CAD by four radiologists (two were experienced and another two inexperienced) blinded to colonoscopy findings. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of detected colonic polyps, as well as the areas under the ROC curves (Az value) with and without CAD were calculated.

Results  CAD increased the overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the colonic polyps detected by experienced and inexperienced readers. The sensitivity in detecting small polyps (5–9 mm) with CAD in experienced and inexperienced readers increased from 82% and 44% to 93% and 82%, respectively (P >0.05 and P <0.001). With the use of CAD, the overall false positive rate and false negative rate for the detection of polyps by experienced and inexperienced readers decreased in different degrees. Among 13 sessile polyps not detected by CAD, two were ≥1.0 cm, eleven were 5–9 mm in diameter, and nine were flat-shaped lesions.

Conclusions  The application of CAD in combination with CTC can increase the ability to detect colonic polyps, particularly for inexperienced readers. However, CAD is of limited value for the detection of flat polyps.

     

推进式电子小肠镜的临床应用评价

目的 评价推进式电子小肠镜临床应用的适应证、检查范围和临床价值. 方法 对多项检查阴性、疑诊小肠病变的41例患者行推进式电子小肠镜检查,采用双人操作法. 结果 41例中成功完成检查者40例.小肠镜前端可达到Treitz韧带下30～100cm,发现十二指肠、空肠病变12例（占29.3%）,食管、胃病变8例.未发生与操作相关的严重并发症. 结论 推进式电子小肠镜是一种安全、可靠的十二指肠和上段空肠疾病的检查手段.     

A leiomyosarcoma of the small bowels causing obscure gastrointestinal bleeding diagnosed by capsule endoscopy

An 80-year-old woman presented with recurrent occult gastrointestinal bleeding requiring blood transfusions. She underwent endoscopy and colonoscopy that failed to identify the cause of bleeding. An enteroscopy revealed duodenal arteriovenous malformation that was cauterized. However, anemia and occult gastrointestinal bleeding recurred. A repeat enteroscopy was negative. A wireless capsule endoscopy showed a lesion in the small bowel. Pathology revealed a leiomyosarcoma. This case confirms the importance of capsule endoscopy in the diagnosis of obscure bleeding and detection of small bowel tumors.     

胶囊内镜在胃肠疾病中的诊断价值及其临床初步应用

目的探讨胶囊内镜在胃肠疾病诊断中的价值及其初步应用效果。方法分析2003年6月至2004年9月间行胶囊内镜的38例次检查结果。结果38例中，不明原因消化道出血16例，病变检出率为87．5％，以血管病变为多见（9／16例）；证实2例克罗恩病累及小肠；腹痛、腹部不适检查11例，诊断为胃炎8例，十二指肠球炎2例，球部溃疡1例；6例体检患者，诊断为胃炎5例，小肠滤泡增生1例；2例消瘦患者均发现有小肠滤泡增生；1例外伤后出血患者，胶囊内镜检查未能明确出血原因。38例胶囊均能自然排出体外，无并发症发生。患者的食管、胃、小肠均较清晰。结论胶囊内镜检查安全，无创伤，尤其适用于不明原因消化道出血和小肠疾病的诊断。     

小肠深段内镜检查在克罗恩病诊断中的价值

目的探讨胶囊内镜(CE)、双气囊小肠镜(DBE)进行的小肠深段内镜检查(DSBE)在克罗恩病(CD)诊断中的价值。方法归纳并分析2004年01月～2008年12月5年间南方医院确诊且接受CE、DBE检查的54例CD患者的消化道内镜及相关临床资料。结果患者行DSBE的主要指征为疑似CD(42.6%)及不明原因性消化道出血(25.9%)。小肠深段病变的镜下形态以非特异性为主,多呈节段性分布。小肠DSBE明显优于钡剂影像检查;DSBE病变检出率(92.6%)高于结肠镜检查(75.9%,P=0.017),其所提供的CD特征性表现,如节段性肠段分布、肠腔变形,较结肠镜检查明显增加。DSBE能显著改善患者的诊断情况,但倾向于提供疑似CD的指导性判断。结论 DSBE有助于小肠段CD病变的检出及受累范围的评估,为CD的诊断、鉴别和复查等提供依据和指向;适当选用DSBE并将其结果与常规影像、胃肠镜及临床等资料综合、分析,将增强DSBE在CD诊治中的作用及有效性。     

胶囊内镜在小肠疾病诊断应用中的新进展

胶囊内镜自研制成功以来,其在不明原因消化道出血、小肠肿瘤、克罗恩病、小肠息肉、感染性炎症、寄生虫病、肠道憩室以及吸收不良综合征等小肠疾病的诊断和监测领域应用日益广泛。在临床应用过程中,它既弥补了传统胃肠道检查手段的不足,但也显露出一些弊端。该文就胶囊内镜的发展及临床应用领域最新进展予以综述。     

消化道出血患者的胶囊内镜检查

目的 评价胶囊内镜在消化道出血患者中的诊断价值。方法 对53例不明原因消化道出血患者、22例因心肺脑功能不全无法耐受常规胃肠镜检查的消化道出血患者，采用M2A胶囊内镜进行胃肠道检查。结果 75例中有74例（98．6％）完成检查，发现消化道病变64例，检出率86．5％，包括胃部病变4例，小肠病变58例，结肠病变2例；41例（55．4％）检出出血病因。22例在胶囊内镜检查后，采用双气囊小肠镜对胶囊内镜检查结果予以验证，发现18例的病因诊断和定位相符。结论胶囊内镜对消化道出血，尤其是小肠源性出血具有较高的诊断价值。     

Obscure GI bleeding due to gastrointestinal stromal tumor (GIST) diagnosed by capsule endoscopy

Gastrointestinal stromal tumor (GIST) is a submucosal tumor which is most commonly found in the stomach and less commonly in small bowel. Small bowel GIST can be difficult to diagnose by conventional imaging and endoscopy techniques. We report a case of obscure GI bleeding due to a stromal tumor (GIST) of the jejunum diagnosed by video capsule endoscopy.     

胶囊内镜对小肠疾病诊断价值的初步研究

目的:探讨胶囊内镜在小肠疾病特别是不明原因消化道出血诊断中的应用价值。方法:分析2006年8月~2007年10月,我院消化内科对24例怀疑小肠疾病患者(其中不明原因消化道出血者21例),行OMOM胶囊内镜检查的临床资料。结果:24例受检者中,小肠息肉7例,小肠新生物2例,小肠血管畸形1例,小肠克罗恩病1例,小肠炎症2例,小肠钩虫病2例,阴性9例,病变检出率为62.5%,其中部分病例经手术病理证实。整个操作过程患者耐受性佳,无任何并发症,检查成功率100%。结论:胶囊内镜检查操作简单、安全、无创伤,尤其适用于年老体弱、合并其他慢性疾病或不能耐受有创性检查的患者。对小肠疾病尤其是不明原因消化道出血具有较高的诊断价值,可以作为小肠出血或经胃镜、结肠镜检查阴性患者的首选检查方法。     

胶囊内镜对不明原因消化道出血患者临床诊断价值

目的：探讨胶囊内镜对不明原因消化道出血的诊断价值。方法：应用M2A胶囊内镜检查系统对90例经胃镜、肠镜检查阴性的消化道出血患者进行检查。结果：90例不明原因消化道出血患者共进行92次胶囊内镜检查，检查成功率为94．57％（87／92），其中急性大量出血组检查成功率为84．0％（21／25），慢性显性出血组检查成功率为98．51％（66／67），两者经χ^2检验有显著性差异（P〈0．05）。在检查成功的患者中，胶囊内镜的病变检出率为85．06％，假阴性率17．24％。急性大量出血组病变检出率80．95%，假阴性率23．81％；慢性显性出血组病变检出率86．36%，假阴性率15．15％，经χ^2检验均无显著性差异（P〉0．05）。结论：胶囊内镜对不明原因消化道出血有较高的检出率，可以作为小肠出血的首选检查方法。     

胶囊内镜在诊断不明原因消化道出血中的临床应用

目的探讨胶囊内镜在不明原因消化道出血患者中的诊断价值和临床应用。方法对54例经胃镜和结肠镜检查未发现出血病灶不明原因消化道出血的患者采用胶囊内镜检查,总结分析其临床资料。结果 52例患者顺利完成检查,其中28例发现小肠病变,阳性检出率为51.8%。胶囊内镜检查中无任何不适和并发症。结论胶囊内镜应用于临床以来,为小肠无创性、可视化性检查开创了一个新领域,并已成为诊断小肠疾病的重要手段。