Diagnostic yield of wireless capsule enteroscopy in comparison with computed tomography enteroclysis

BACKGROUND AND STUDY AIMS: It is still difficult to visualize changes in the small intestine. Wireless capsule enteroscopy is a new method that promises to provide new insights into the small intestine. In a prospective study, the diagnostic yield of wireless enteroscopy was therefore compared with computed tomography (CT) enteroclysis. PATIENTS AND METHODS: Twenty-two patients with suspected small-bowel pathology underwent CT enteroclysis and wireless capsule enteroscopy examinations, conducted by two independent blinded investigators. The results of the two investigations (diagnoses and the number, extent, and location of lesions detected) were compared by a third investigator. RESULTS: The patients included in the study had obscure gastrointestinal bleeding (n = 8), Crohn's disease (n = 8), unexplained diarrhea (n = 5), or suspected carcinoid tumor (n = 1). Pathological lesions were detected using capsule enteroscopy in 13 patients (59 %) and using CT enteroclysis in eight (36 %; P = 0.12). In seven patients (one case each of colonic Crohn's disease, diverticulitis, Meckel's diverticulum, carcinoid tumor, mesothelioma, colonic polyps, and irritable bowel syndrome), no pathological changes were found in the small intestine using either method. The diagnosis was established by wireless capsule enteroscopy in four patients with obscure bleeding, whereas CT enteroclysis was positive in only one patient ( P = 0.1). Crohn's disease was found in two patients with unexplained diarrhea. Small-bowel lesions were identified in six patients with known Crohn's disease using capsule enteroscopy or CT enteroclysis. The only side effect of wireless capsule enteroscopy observed was abdominal pain in one patient with Crohn's disease. There were no serious side effects with CT enteroclysis. CONCLUSIONS: Wireless capsule enteroscopy detects more small-bowel lesions than CT enteroclysis in patients with obscure gastrointestinal bleeding and Crohn's disease.     

Wireless capsule endoscopy in a patient with obscure occult bleeding

A case of obscure/occult bleeding in a 39-year old man with a 7-year history of chronic fatigue and iron-deficiency anemia is presented here. Esophagogastroduodenoscopy, push enteroscopy, ileocolonoscopies, and a magnetic resonance imaging small-bowel follow-through did not reveal any abnormalities. Multiple inflammatory lesions with fibrin-covered ulcers and petechial bleeding in the area of the lower jejunum and ileum were diagnosed only with capsule endoscopy. One ulcer located near the ileocecal valve was then biopsied during a repeat ileocolonoscopy, and the histology showed signs of Crohn's enteritis. The further treatment approach was changed, with medical treatment being initiated and intraoperative enteroscopy being averted. Wireless capsule endoscopy clarified the cause of the obscure/occult bleeding in this patient and contributed to the diagnosis and endoscopic imaging of an isolated Crohn's enteritis, which is the cause of bleeding in approximately 10 - 20 % of cases of occult bleeding.     

Small bowel capsule endoscopy: a systematic review

Wireless capsule endoscopy offers a revolutionary diagnostic tool for small bowel diseases. Since its formal introduction, it has become an integral part of the diagnostic evaluation for obscure gastrointestinal bleeding. This relatively noninvasive imaging modality offered by small bowel capsule endoscopy is appealing to both patients and providers and consequently, the desire to expand its diagnostic role continues to grow. The use of CE in the diagnosis of Crohn disease and chronic diarrhea is being further investigated, as is the potential of employing this technique as a cancer surveillance mechanism in patients with hereditary polyposis syndromes which may involve the small bowel. This review article discusses the current indications for small bowel capsule endoscopy, the results of capsule endoscopy in patients with obscure gastrointestinal bleeding and small bowel diseases, and patient outcomes following capsule endoscopy. Capsule endoscopy is compared with traditional diagnostic modalities, including small bowel series, enteroclysis, CT, and push enteroscopy. Small bowel capsule endoscopy is the procedure of choice to evaluate obscure gastrointestinal bleeding, and is superior to radiographic procedures in detecting Crohn disease of the small bowel.     

Obscure gastrointestinal bleeding and small bowel pathology: comparison between wireless capsule endoscopy and multidetector-row CT enteroclysis

Obscure gastrointestinal bleeding is defined as bleeding of unknown origin, that persists or recurs after negative conventional barium contrast studies and upper and lower tract endoscopy. The causes of such a bleeding frequently arise in the small bowel, and they are represented by mucosal vascular abnormalities, neoplasms and other conditions such as Crohn's disease, Meckel's diverticulum, and vasculitis. Conventional barium contrast studies and push enteroscopy allow only a limited small bowel examination; moreover, intraoperative endoscopy may be inconclusive, since the small bowel is difficult to evaluate given its length and tortuous course. In the same way, angiographic diagnosis is stricktly related to the activity rate of hemorrhage. Wireless capsule endoscopy and multidetector-row CT enteroclysis are two recently developed minimally invasive techniques that may provide a complete small bowel examination, the first offering a direct visualization of the mucosal aspect, the second allowing evaluation of mural and extramural pathologies. This review is an update of the technique and clinical application of capsule endoscopy and multidetector-row CT enteroclysis in patients suffering from obscure small bowel bleeding.     

Outcome of capsule endoscopy in determining indication and route for push-and-pull enteroscopy

BACKGROUND AND STUDY AIM: Video capsule endoscopy and push-and-pull enteroscopy (PPE), both allow a complete examination of the small bowel in patients with suspected intestinal disorders. Due to the invasiveness of PPE, indications should probably be selective. The aim of the present prospective study was to evaluate the outcome of an approach whereby capsule endoscopy was used to select patients in whom PPE was indicated. PATIENTS AND METHODS: 164 patients were included (90 men; age 54+/-18 years) with various indications for small-bowel investigation, such as obscure bleeding (n=88), suspected Crohn's (n=14) or celiac (n=12) disease, or known or strongly suspected localized diseases such as neoplasms (n = 18) for biopsy. Four patients with a suspected intestinal stenosis underwent PPE without prior capsule endoscopy. In the remaining 160 patients, who had a capsule endoscopy, PPE was selected if there were lesions requiring biopsy or angiodysplasias to be treated by argon plasma coagulation (APC). Regarding the insertion route, an anal PPE was indicated if the capsule transit time from ingestion to arrival at the lesion was >or= 75 % of the total time from ingestion to arrival at the cecum. After gut cleansing, PPE was performed with general anesthesia, and the small bowel was examined until the lesion was reached or the scope could not be advanced further. If the suspected lesion had not been reached, a second procedure was performed through the alternative route, under the same conditions. RESULTS: The diagnostic yield of capsule endoscopy was 75 %. According to the indications, 47 PPE procedures were performed in 42 patients, including 33 through the oral route, 4 through the anal route and 5 combined ones. Indications were: suspicion of intestinal tumor (n=13), celiac disease with chronic bleeding (n=4), suspicion of Crohn's disease (n=3), treatment of significant arteriovenous malformations (AVMs) (n=10), diffuse enteropathies (n=3), nonsteroidal anti-inflammatory drug (NSAID)-related conditions (n=2), and obscure digestive bleeding (n=3). Lesions detected by capsule endoscopy were reached by PPE in all but two cases. The positive predictive value (PPV) of capsule endoscopy to make a correct indication for PPE was 94.7 % and the negative predictive value (NPV) was 98.3 %. The PPV and NPV of a time index of > 0.75 to start via the anal route were 94.7 % and 96.7 %. No complications were observed and all patients were discharged the day after the procedure. Follow-up at 9 months showed that capsule endoscopy followed by PPE had positively influenced the management of 90.5 % of the patients. CONCLUSIONS: The use of capsule endoscopy as a filter for PPE results in effective management of patients with various intestinal diseases. Capsule endoscopy can also direct the choice of route of PPE; a time index of > 0.75 appears to reliably indicate an anal route so that a double procedure is required in only about 12 % of cases.     

Prevalence of occult celiac disease in patients with iron-deficiency anemia: a prospective study

BACKGROUND: Occult celiac disease has been reported in 0 to 6% of adults presenting with iron-deficiency anemia. Most prior studies have been retrospective or screened only a selected population of patients with small bowel biopsies. To more accurately define the true prevalence of this disorder in patients presenting with iron-deficiency anemia (with or without stool hemoccult positivity), we initiated this prospective study. METHODS: Esophagogastroduodenoscopy with small bowel biopsies and colonoscopy were performed in all iron-deficiency anemia patients (including those with hemoccult-positive stools) referred to the gastroenterology service during a 2-year period (1998-2000). Inclusion criteria included iron-deficiency anemia as defined by a serum ferritin < 25 ng/ml and anemia with hemoglobin < 12 g/dl. Patients were excluded for documented prior erosive, ulcerative, or malignant disease of the gastrointestinal tract, previous gastrointestinal surgery, overt gastrointestinal bleeding within the past 3 months, or inability to access the duodenum for biopsy. All patients underwent upper endoscopy with more than two biopsies of the distal duodenum and colonoscopy. A serum immunoglobulin A antiendomysial antibody test was to be performed in those patients with a positive small bowel biopsy to confirm the diagnosis of celiac disease. RESULTS: One hundred five of 139 consecutive patients with iron-deficiency anemia met the inclusion criteria and were enrolled in the study. Fifty-seven men (mean age, 51.6 yr) and 48 women (mean age, 54.1 yr) constituted the study population. The demographics of this study population included 36 blacks, 38 Hispanics, and 22 whites. Nine patients were of mixed or unknown ethnic background. Forty-three and eight-tenths percent of the men and 37.5% of women had hemoccult-positive stools, accounting for a total of 40.9% of the study patients. Upper endoscopic findings included gastritis in 22.8%, gastric ulcers in 9.5%, duodenitis in 8.5%, esophagitis in 7.6%, Barrett's ulcer in 2.8%, duodenal ulcer in 2.8%, gastric polyp in 2.8%, and celiac disease in 2.8%. Colonoscopic findings included colon polyps in 21.9%, diverticula in 10.4%, and hemorrhoids in 16.1%. Multiple findings were found in 32.3% of patients, and there were no findings in 28.5% of patients. CONCLUSION: The prevalence of occult celiac disease in this prospective study of patients presenting with iron-deficiency anemia was 2.8%. A significant number of other gastrointestinal lesions amenable to therapy were also found on upper and lower endoscopy in these patients. Given the treatable nature of celiac disease, it should be screened for in patients with unexplained iron-deficiency anemia with or without hemoccult-positive stools.     

Small bowel endoscopy

Video capsule endoscopy continues to be the major focus in papers dealing with diagnostic small-bowel endoscopy. Although capsule endoscopy is used for a variety of indications, its major field of application is still obscure bleeding from the small intestine, where it can be regarded as a first-line test. There is increasing evidence that capsule endoscopy for suspected Crohn's disease may be diagnostic in individual cases after inconclusive conventional tests. Push enteroscopy is the clinical reality for biopsy and treatment in the proximal small bowel, whereas intraoperative enteroscopy is used for distal or diffuse small-intestinal disorders. Further reports on double-balloon enteroscopy suggest that this method may be able to replace at least intraoperative enteroscopy in many circumstances. The availability of specific antibody tests for celiac disease is leading to recurrent interest in endoscopy and histology, showing that villous atrophy and lymphocytic infiltrates are typical, but not specific, findings.     

Small-bowel endoscopy

The role of small-bowel endoscopy in the management of small-bowel diseases is still evolving. During the last year, capsule endoscopy has developed from being an emerging method in gastroenterology to become a clinical reality, and it must now be considered critically. A number of peer-reviewed studies have been published that compare the method with push enteroscopy in patients with obscure gastrointestinal bleeding. In other studies, capsule endoscopy has been compared with traditional radiographic methods of examining the small bowel. The potential of capsule endoscopy for diagnosing small-bowel diseases has also been evaluated, particularly in patients with suspected Crohn's disease. Although this innovative diagnostic method has now entered clinical practice, it must be stressed that both push enteroscopy and intraoperative enteroscopy still have a precise and valid role in the management of patients with small-bowel diseases, as may be seen from several of the studies that are reviewed here. Capsule endoscopy will probably become a first-line tool for detecting abnormalities of the small bowel, and very probably this will entail redefining some diagnostic algorithms for diseases involving the small bowel. Nevertheless, further studies are required before today's clinical practice can be definitively modified, and these should make particular reference to the outcome in patients who undergo capsule endoscopy.     

胶囊内镜对86例患者小肠疾病的诊断分析

目的：分析评价胶囊内镜对小肠疾病的诊断价值。方法：对86例怀疑有小肠疾病的患者行胶囊内镜检查,并分析检查结果。结果：共检出小肠病变48例（55.8%）。其中小肠血管发育异常17例,小肠绒毛萎缩10例,小肠息肉5例,小肠溃疡3例,小肠炎症8例,小肠隆起性病变2例,小肠钩虫病1例,疑似炎症性肠病1例,末端回肠炎症伴回盲部占位1例。不明原因消化道出血23例中,检查出小肠病变19例,阳性率82.6%,其中小肠血管发育异常或伴活动性出血11例,小肠溃疡3例,钩虫病1例,小肠息肉3例,小肠多发隆起灶1例。胶囊内镜正常电池范围内对小肠检查情况：86例中有14例未能完成抵达回盲部,占16.3%。但其中10例已经发现小肠病变。结论：胶囊内镜对小肠疾病诊断率高,尤其适用于不明原因的消化道出血患者。     

Locally advanced small-bowel adenocarcinoma missed primarily by capsule endoscopy but diagnosed by push enteroscopy

Wireless-capsule-endoscopy is a new painless method that is able both to visualize the entire small bowel and to detect even small lesions. We report here the case of a patient in whom a locally advanced small-bowel adenocarcinoma was initially missed on capsule endoscopy, but was diagnosed by subsequent push enteroscopy. Capsule endoscopy was carried out in a 47-year-old patient with a history of obscure gastrointestinal bleeding, iron-deficiency anemia, and a lack of symptoms suggestive of stenosis. The capsule imaging revealed angiodysplasias in the jejunum, but no other abnormalities. Push enteroscopy was carried out to allow argon plasma coagulation treatment of the angiodysplasias that had been detected; it revealed a polypoid tumor 20 mm in diameter at 150 cm from the incisors, with the capsule endoscope still located proximal to the tumor and with its optical dome turned towards the push enteroscope. Clinical staging and subsequent surgical resection showed a locally advanced adenocarcinoma (pT4, pN0 (0/7), pMx, G3).[nl]Small-bowel tumors within the reach of push enteroscopy may be missed by capsule endoscopy. Although wireless capsule endoscopy is a major advance in the investigation of the small bowel, well-designed clinical studies still need to define the precise algorithm for diagnostic work-up of suspected small-bowel diseases.     

Extraction of entrapped capsules from the small bowel by means of push-and-pull enteroscopy with the double-balloon technique

The new technique of push-and-pull enteroscopy using the double-balloon technique (double-balloon enteroscopy) makes it possible to remove swallowed foreign bodies causing intestinal obstruction deep in the small bowel without the need for surgical laparotomy. This report describes two cases of enteroscopic removal of entrapped capsules. In one patient with acute recurrent intestinal bleeding and recurrent abdominal pain, Crohn's disease had been suspected on capsule endoscopy. The second patient, with known Crohn's disease, was suffering from abdominal pain and underwent capsule endoscopy for investigation of the small bowel. Prior enteroclysis had not revealed stenoses in either patient. An oral approach was chosen and the capsules were identified approximately 140 cm and 310 cm from the pylorus, respectively, in front of stenoses. The capsule endoscopes were removed successfully in both patients by means of push-and-pull enteroscopy using a new enteroscope device.     

Small-bowel tumors diagnosed by wireless capsule endoscopy: report of five cases

Tumors of the small bowel, both benign and malignant, are relatively uncommon. As the symptoms are vague and conventional diagnostic tests are unsatisfactory, these tumors often present a clinical, radiological, and endoscopic challenge. We report here on five patients in whom small-bowel tumors were diagnosed using wireless capsule endoscopy. The indications for capsule endoscopy were: obscure gastrointestinal bleeding in four patients (one jejunal capillary hemangioma, one ileal hemangiosarcoma, and two jejunal gastrointestinal stromal tumors) and chronic abdominal pain in one patient (ileal carcinoid). Wireless capsule endoscopy, a new endoscopic method, promises to improve the diagnosis of deep small-bowel pathology.     

Small bowel tumors

WCE is a noninvasive diagnostic technique that visualizes the entire small intestine and identifies lesions in parts of the small bowel not reached by traditional endoscopy. Although further studies are needed to define the exact role of WCE for diagnosing and managing small bowel tumors, its sensitivity has been shown to be superior to PE and small bowel follow-through in regard to diagnosing patients who have obscure GI bleeding, the most common indication for capsule endoscopy in the authors' series of patients with documented small bowel tumors. As more material is published, capsule endoscopy likely will be confirmed to be the diagnostic procedure of choice in patients with suspected small bowel tumors.     

Capsule endoscopy: a review

Capsule endoscopy (CE) is a novel technology that allows direct noninvasive visualization of the entire small intestine. CE permits a detailed examination in the ambulatory setting, allowing identification of clinically relevant lesions, and it is appealing to both patients and providers. There are two types of capsules that are currently commercially available: one specifically designed to view the small bowel and the other for the esophagus. Common indications for small bowel CE include obscure gastrointestinal bleeding, initial diagnosis of suspected Crohn's disease, and other small bowel pathology. The esophageal capsule is currently used to evaluate Barrett esophagus and esophageal varices. It is a well-tolerated procedure with relatively few complications. Although CE performance may be superior to existing technologies, its impact on clinical decision-making and patient outcomes are of even greater importance. Herein lies a review of the latest information on CE, its indications, complications, future utilities, and developing technology.     

Small-bowel endoscopy

This review of the literature on endoscopy of the small bowel focuses on published reports, and does not include abstracts. The literature was reviewed for the period September 2001 to September 2002. MEDLINE was searched under the topics of "small-bowel endoscopy", "small bowel", "enteroscopy", "obscure bleeding", and "wireless endoscopy", and a hand search was also carried out of the major gastroenterology journals, along with a review of the tables of contents of all journals that could be identified as being related to gastroenterology or gastrointestinal endoscopy. Sonde small-bowel enteroscopy is no longer an option, and has been rightfully retired as an investigation tool for the small bowel. There is still a place for further evaluation of push enteroscopy, as evidenced by the 11 papers published since the last review of small-bowel endoscopy in 2002. In the field of intraoperative enteroscopy, only one series and a handful of case reports have appeared. By contrast, wireless capsule endoscopy of the small bowel has captured the imagination of gastroenterologists throughout the world. Up to 2003, there have not been many published papers concerning this new diagnostic modality, since patients with obscure gastrointestinal bleeding or suspected small-bowel disease are relatively scarce. Large numbers of abstracts concerning capsule endoscopy have been submitted for presentation at major gastroenterology and gastrointestinal endoscopy meetings over the past 2 years, and the enthusiasm for this new technique of small-bowel imaging has increased with reports of its successful application.     

Video capsule endoscopy in small-bowel malignancy: a multicenter Belgian study

BACKGROUND AND STUDY AIMS: Early diagnosis of small-bowel tumors is crucial for therapy. Video capsule endoscopy has improved the diagnosis of small-bowel diseases, but data concerning the role of this technique in detecting small-bowel malignancy are scarce. The aim of this paper was to review all capsule endoscopy findings at Belgian hospitals, in order to evaluate the diagnostic yield of capsule endoscopy in the field of small-bowel malignancy. PATIENTS AND METHODS: For this retrospective study, the seven Belgian academic hospitals where the device was being used were asked to review the findings obtained by means of video capsule endoscopy, and to collect information about the cases of small-bowel malignancy. RESULTS: In total, 443 capsule endoscopies were performed up to November 2004, and 11 malignant small-bowel processes were detected (2.5%). The most frequent indications for performing capsule endoscopy in those 11 cases were intestinal bleeding of undefined origin or iron-deficiency anemia. The mean number of diagnostic procedures performed before capsule endoscopy was 3.6. The capsule endoscopy results had a diagnostic yield of 1.6% after classical work-up. In 55% of these cases, capsule endoscopy findings had an influence on therapy. CONCLUSIONS: Tumors of the small bowel remain a rare condition. Video capsule endoscopy is able to detect tumors undiagnosed by classical procedures in about 1.6% of cases and has an impact on the therapy in 55% of the tumor cases.     

两种不同重量及大小的胶囊内镜之间胃肠通过时间及全小肠检查完成率的对比*

目的探究两种不同重量及大小的胶囊内镜之间胃通过时间(GTT)、小肠通过时间(SBTT)及全小肠检查完成率(CR)是否不同。方法回顾性纳入因各种原因而接受了OMOM胶囊内镜检查或Miro Cam胶囊内镜检查(比OMOM胶囊更小且更轻)的患者,对比分析了这两种不同重量及大小的胶囊内镜的GTT、SBTT以及CR。结果共纳入1 448名符合条件的患者,其中OMOM组628例,Miro Cam组820例。总体上,在工作时间校正后SBTT和CR方面,两组之间差异无统计学意义(P0.05)。在克罗恩病或可疑克罗恩病患者中,OMOM组的GTT明显长于Miro Cam组[(53.4±52.6)min比(41.1±47.9)min,P=0.022)];在消化道出血患者中,OMOM组的GTT明显短于Miro Cam组[(42.1±44.8)min比(62.0±78.6)min,P=0.016]。结论总体来说,两种不同重量及大小的胶囊内镜之间的GTT、SBTT及CR没有明显差别,但在克罗恩病或可疑克罗恩病患者中,更轻且更小的胶囊内镜的GTT较短;而在消化道出血患者中,更轻且更小的胶囊内镜的GTT较慢。     

Video capsule endoscopy — state of the art and indications

Wireless capsule endoscopy represents a major milestone in the evolution of small bowel enteroscopy, and enables visualization of the entire small bowel in a noninvasive manner, without necessity for sedation. Indications for the test include, but are not limited to evaluation of obscure gastrointestinal bleed, Crohn disease, small bowel tumors, polyposis syndromes, and Celiac disease. Modifications of the capsule also facilitate its utilization in screening and surveillance for Barrett’s esophagus, esophageal varices, and colorectal cancer. This article is a review of the indications and recommendations regarding the role of capsule endoscopy in current clinical practice.     

OMOM胶囊内镜在老年患者消化道疾病诊断中的应用

目的：探讨胶囊内镜在老年患者消化道疾病诊断中的应用。方法：对129例行OMOM胶囊内镜检查的患者资料行回顾性分析。结果：129例患者中完成胶囊内镜检查118例,发现异常103例,阳性检出率87.3%。发现食管、胃、小肠、结肠病变分别为3例、38例、92例、7例,占阳性发现率分别为2.9%、36.9%、89.3%、6.8%。完成胶囊内镜检查的91例消化道出血患者和25例腹痛、腹泻患者分别发现小肠病变75例（82.4%）和17例（68%）。其中黏膜下隆起及新生物、炎症病变和血管病变最为常见。检查过程中患者无任何不适。结论：OMOM胶囊内镜检查方法安全性好,对老年患者消化道疾病有较高的诊断价值。建议检查前对患者身体进行适当的评估,采取相应措施提高检查质量。     

Use of capsule endoscopy for established Crohn's disease

There remains significant uncertainty regarding the role of capsule endoscopy in the setting of known inflammatory bowel disease (IBD). Capsule endoscopy should be considered for patients who have indeterminate colitis, who are failing medical therapy or who may require colectomy, who have truly unexplained symptoms based on standard endoscopy and radiography, and who have IBD and obscure bleeding. Although capsule endoscopy clearly detects small bowel pathology with greater sensitivity than other methods, the implications of these lesions are not fully understood. At this time, use of capsule endoscopy as a tool for the evaluation of mucosal healing or for prognostication of post-operative recurrence remains investigational.