Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding

BACKGROUND: The development of wireless capsule endoscopy allows painless imaging of the small intestine. Its clinical use is not yet defined. The aim of this study was to compare the clinical efficacy and technical performance of capsule endoscopy and push enteroscopy in a series of 50 patients with colonoscopy and gastroscopy negative gastrointestinal bleeding. METHODS: A wireless capsule endoscope was used containing a CMOS colour video imager, transmitter, and batteries. Approximately 50,000 transmitted images are received by eight abdominal aerials and stored on a portable solid state recorder, which is carried on a belt. Push enteroscopy was performed using a 240 cm Olympus video enteroscope. RESULTS: Studies in 14 healthy volunteers gave information on normal anatomical appearances and preparation. In 50 patients with gastrointestinal bleeding and negative colonoscopy and gastroscopy, push enteroscopy was compared with capsule endoscopy. A bleeding source was discovered in the small intestine in 34 of 50 patients (68%). These included angiodysplasia (16), focal fresh bleeding (eight), apthous ulceration suggestive of Crohn's disease (three), tumour (two), Meckel's diverticulum (two), ileal ulcer (one), jejunitis (one), and ulcer due to intussusception (one). One additional intestinal diagnosis was made by enteroscopy. The yield of push enteroscopy in evaluating obscure bleeding was 32% (16/50). The capsule identified significantly more small intestinal bleeding sources than push enteroscopy (p<0.05). Patients preferred capsule endoscopy to push enteroscopy (p<0.001). CONCLUSIONS: In this study capsule endoscopy was superior to push enteroscopy in the diagnosis of recurrent bleeding in patients who had a negative gastroscopy and colonoscopy. It was safe and well tolerated.     

Capsule Endoscopy Versus Push Enteroscopy for Evaluation of Obscure Gastrointestinal Bleeding with 1-Year Outcomes

Because of the low diagnostic yield of standard radiologic tests for identifying sources of obscure gastrointestinal bleeding in the small intestine, we compared wireless video capsule endoscopy with push enteroscopy and small-bowel follow-through. Patients referred to Mayo Clinic, Scottsdale, Arizona, between August and December 2001 for evaluation of obscure gastrointestinal bleeding were potential candidates. Eligible patients had previously inconclusive endoscopy, colonoscopy, small-bowel follow-through, and other radiologic studies. Participants underwent capsule endoscopy and enteroscopy (within 24 hr). The primary end point was localization of any bleeding source, with 1-year telephone follow-up. Capsule endoscopy yielded positive findings in 10 of 20 patients (11 men; mean age, 69 years), 6 of whom had negative enteroscopy and small-bowel follow-through. No patient with negative findings on capsule endoscopy had positive findings on enteroscopy and small-bowel follow-through. At follow-up, 19 patients reported fewer transfusions, gastrointestinal procedures, and hospitalizations. Capsule endoscopy identified more lesions and improved outcomes.Published as an abstract at Digestive Disease Week, San Francisco, California, May 19–22, 2002.     

胶囊内镜在老年人不明原因的消化道出血诊断中的应用

目的探讨M2A胶囊内镜对老年人不明原因的消化道出血的诊断作用。方法对27例不明原因消化道出血的老年患者进行M2A胶囊内镜检查，其中22例经过电子胃镜、结肠镜或小肠气钡双重造影检查，均未明确出血部位；另5例未做过任何检查。结果27例患者中，经M2A胶囊内镜检查发现出血病变20例，检出率为74．1％。检出病变主要为空肠血管发育不良6例，小肠多发息肉4例（其中1例为罕见的Cronkhite-Canada综合征），小肠占位性病变4例，小肠黏膜溃疡7例，小肠黏膜糜烂9例，小肠憩室1例，胃内小动脉出血2例，胃内黏膜糜烂、溃疡5例。有12例患者同时伴有2处或以上的病变。结论M2A胶囊内镜对不明原因的消化道出血部位有较高的检出率，是一种非侵人性的检查方法，尤其适用于老年患者。     

A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding

BACKGROUND: Capsule endoscopy enables noninvasive diagnostic examination of the entire small intestine. However, sensitivity and specificity of capsule endoscopy have not been adequately defined. We, therefore, compared capsule endoscopy by using intraoperative enteroscopy as a criterion standard in patients with obscure GI bleeding. METHODS: Forty-seven consecutive patients with obscure GI bleeding (11 with ongoing overt bleeding, 24 with previous overt bleeding, and 12 with obscure-occult bleeding) from two German gastroenterologic centers were included. All patients who had a prior nondiagnostic evaluation, including upper endoscopy, colonoscopy with a retrograde examination of the distal ileum, and push enteroscopy, underwent capsule endoscopy followed by intraoperative enteroscopy. RESULTS: Capsule endoscopy identified lesions in 100% of the patients with ongoing overt bleeding, 67% of the patients with previous overt bleeding, and 67% of the patients with obscure-occult bleeding. Angiectasias were the most common source of bleeding (n = 22). Capsule endoscopy showed the source of bleeding in 74.4% of all patients. The method was more effective in patients with ongoing bleeding. Compared with intraoperative enteroscopy sensitivity, specificity, and positive and negative predictive values of capsule endoscopy were 95%, 75%, 95%, and 86%, respectively. CONCLUSIONS: Capsule endoscopy has high sensitivity and specificity to detect a bleeding source in patients with obscure GI bleeding. Thus, wireless capsule endoscopy can be recommended as part of the routine work-up in patients with obscure GI bleeding.     

Capsule endoscopy

Video capsule endoscopy is a major innovation that provides high-resolution imaging of the entire small intestine in its entirety. In the 4 years since its introduction, capsule endoscopy has demonstrated its viability as a first-line investigation in patients with obscure gastrointestinal bleeding after a negative esophagogastroduodenoscopy and colonoscopy, and it has a positive impact on the outcome. Video capsule endoscopy is also useful in the evaluation of inflammatory and neoplastic disorders of the small bowel. Its role in children and in the evaluation of esophageal disorders is currently being explored and defined.     

Capsule endoscopy: practical applications.

Few advances in the history of gastroenterology have made as dramatic an impact on the diagnosis of gastrointestinal disease as the development and rapid clinical implementation of wireless capsule endoscopy. Less than 4 years after the landmark publication, capsule endoscopy is widely considered an essential component of the diagnostic workup of obscure gastrointestinal bleeding, and its role is expanding in the diagnosis of small bowel diseases such as Crohn's disease. This review appraises the available literature and highlights practical aspects of capsule endoscopy of interest to the clinician. We discuss safety concerns, optimal preparation for the procedure, diagnostic utility as compared to conventional methods, indications for capsule endoscopy, and outcomes.     

Capsule endoscopy: past,present, and future

A capsule endoscope is a swallowable wireless miniature camera for getting images of the gastrointestinal (GI) mucosa. The initial capsule endoscope model was developed by Given Imaging and approved in Western countries in 2001. Before the introduction of capsule endoscopy (CE) and double-balloon endoscopy (DBE), there was no effective modality for the evaluation and management of patients with obscure GI bleeding. Obscure GI bleeding is defined as bleeding of unknown origin that persists or recurs after a negative initial or primary endoscopy (colonoscopy or upper endoscopy) result. The first capsule endoscope model, which is now regarded as a first-line tool for the detection of abnormalities of the small bowel, was the PillCam SB. It was approved in Japan in April 2007. The main indication for use of the PillCam SB is obscure GI bleeding. Almost the only complication of CE is capsule retention, which is the capsule remaining in the digestive tract for a minimum of 2 weeks. A retained capsule can be retrieved by DBE. There are some limitations of CE in that it cannot be used to obtain a biopsy specimen or for endoscopic treatment. However, the combination of a PillCam SB and DBE seems to be the best strategy for management of obscure GI bleeding. Recently, several new types of capsule endoscope have been developed, such as Olympus CE for the small bowel, PillCam ESO for investigation of esophageal diseases, and PillCam COLON for detection of colonic neoplasias. In the near future, CE is expected to have a positive impact on many aspects of GI disease evaluation and management.     

A case of multiple gastrointestinal stromal tumor of the jejunum which was diagnosed by capsule endoscopy

More than 90% cases of chronic gastrointestinal bleeding can be diagnosed by upper endoscopy and/or colonoscopy, and therefore, obscure gastrointestinal bleeding has been defined as bleeding of unknown origin that persists after these conventional endoscopic evaluation. Gastrointestinal stromal tumors (GISTs) are rare tumors, but the most common form of mesenchymal tumors of the gastrointestinal tract. Small bowel is the second most common primary site for GISTs, and accounts for 2-10% of chronic bleeding sites. GISTs usually present as a sporadic and solitary tumor, and a minority of the cases of multiple GISTs are discovered as forms of hereditary or idiopathic tumor syndromes. Small bowel tumor has been difficult to diagnose because of absence of accurate and proper diagnostic tools. Recently developed wireless capsule endoscopy helps in the diagnostic work-up of small bowel diseases. We report a case of multiple jejunal GISTs presenting melena in a 39-year-old male, which was diagnosed with wireless capsule endoscopy.     

Wireless capsule endoscopy for diagnosis of small intestinal lesions

Background: Capsule endoscopy represents a new and highly innovative method of visualizing the small intestine. The aim of the present study was to evaluate the practicality, usefulness and diagnostic yield of capsule endoscopy in a group of patients with suspected small intestinal disease. Methods: Eleven patients underwent capsule endoscopy using the M2A Capsule Endoscope? (Given Imaging, Yogneam, Israel). The indications for the procedure were: obscure gastrointestinal (GI) bleeding in seven patients, evaluation of Crohn's disease in three patients and unexplained abdominal pain and weight loss in one patient. Results: Abnormalities were detected in six of 11 patients overall. Detection of abnormalities was highest among patients with obscure GI bleeding where active bleeding and/or the source of bleeding was identified in five of the seven (71.4%) patients. One of the three patients with Crohn's disease had an ileal ulcer detected, while the remaining patient with unexplained weight loss and pain had a normal examination. Conclusion: We have found in our preliminary experience that capsule endoscopy is a useful and practical procedure to perform especially for evaluation of obscure GI bleeding.     

胶囊内镜联合多排螺旋CT诊断不明原因消化道出血的临床研究

目的探讨胶囊内镜（capsuleendoscopyCE）联合多排螺旋cT（MSCT）在不明原因消化道出血中的诊断作用和价值。方法收集不明原因消化道出血患者80例,进行胶囊内镜及多排螺旋cT检查,统计两种检查手段病变的检出率及其部位并进行分析。结果80例中CE诊断阳性46例,诊断阳性率为57．5％;MSCT诊断阳性33例,诊断阳性率为41．3％,P〈0．05;CE和MSCT联合诊断的阳性率为63．8％,与CE相比P〉0．05,与MSCT相比P〈0．05;CE和MSCT的诊断一致率为71．3％;另有34例在检查后进行了外科手术,检出病变34种;CE和MSCT均有病变漏诊,但MSCT漏诊更多。结论①cE联合MSCT检查对不明原因消化道出血的诊断阳性率较cE有所提高,但无统计学意义。②CE联合MSCT检查在判断小肠肿瘤的病变性质及肠外情况的了解中具有优势,建议对不明原因消化道出血进行CE和MSCT的联合检查。     

国产OMOM胶囊内镜对消化道疾病的诊断价值

目的探讨国产OMOM胶囊内镜在消化道疾病,特别是小肠疾病中的诊断价值。方法总结分析我院2008年1月至2009年5月应用国产OMOM胶囊内镜检查59例患者,所有患者均经胃镜、结肠镜、腹部彩超等检查未发现可解释疾病的原因,其中出血组13例,腹痛组46例。采用甘露醇行肠道准备。结果59例中检查出小肠疾病26例。OMOM胶囊内镜性能稳定,图像清晰,摄像胶囊所携带的电池一般能满足对全小肠的观察。胶囊内镜在胃内通过时间9min～149min,胃内平均滞留时间44min,小肠通过时间83min～398min,小肠平均通过时间195min。有3例胶囊滞瘤体内,未出现其他不良反应。结论国产OMOM胶囊内镜对小肠疾病的诊断阳性率高,安全无痛苦,具有较好的临床诊断价值,尤其适用于不明原因消化道出血的患者。     

Diaphragm disease after use of nonsteroidal anti-inflammatory agents: first report of diagnosis with capsule endoscopy

Diaphragm disease of the small intestine is part of the spectrum of diseases associated with injury to the gastrointestinal tract induced by nonsteroidal anti-inflammatory drugs. Standard endoscopy or contrast studies of the small intestine rarely identify these lesions. The diagnosis usually is established at the time of surgery. We report the case of a 72-year-old woman with obscure gastrointestinal bleeding and intermittent obstruction of the small intestine who had had multiple hospitalizations and extensive testing. The patient had been treated with nonsteroidal anti-inflammatory drugs for osteoarthritis. A radiograph of the small intestine with barium contrast revealed no abnormalities, so capsule endoscopy was performed. Capsule endoscopy showed multiple small intestinal strictures beyond which the capsule could not pass. After the patient experienced continued symptoms suggestive of intermittent partial obstruction of the small intestine, computed tomography showed the capsule within a dilated loop of intestine adjacent to a stricture. After 9 days of conservative medical therapy and worsening symptoms, the patient required an exploratory laparotomy. The capsule was located in a 12-cm segment of intestine with 4 diaphragm-like lesions. Pathologic study found submucosal lesions with features identical to those of neuromuscular and vascular hamartoma (eg, mature, reactive tissue elements of smooth muscle, dense fibrous tissue, and nerve tissue bundles with scattered ganglion cells and vessels). No manifestations of Crohn disease were evident. This case represents the first diagnosis with capsule endoscopy of diaphragm disease of the small intestine with pathologic features of neuromuscular and vascular hamartoma.     

Video capsule endoscopy: what is the future?

Video capsule endoscopy (VCE) that was launched 10 years ago has become a first-line procedure for examining the small bowel, especially in the case of obscure gastrointestinal bleeding. Other major indications include Crohn disease (CD), celiac disease, and intestinal polyposis syndrome. In the case of small bowel diseases, the use of VCE must be integrated in?a?global diagnostic and therapeutic approach. More recently, wireless endoscopy has been adapted for examining the colon, opening up larger perspectives for colorectal cancer screening or colon examination. Technologic modifications of the second-generation colon capsule increase the sensitivity of this method for detecting polyps. Other new developments, including remote magnetic manipulation, power management, drug delivery capsule, microbiopsy capsule, and adaptation of technologies such as chromoendoscopy, are sure to enhance the capabilities of wireless endoscopy in gastrointestinal disorders.     

Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: Results of a pilot study

BACKGROUND: A video capsule has been developed to acquire photographic images of the small intestine during normal peristaltic motion. METHODS: Patients between 21 and 80 years of age referred for enteroscopy because of obscure GI bleeding were offered entry into a trial in which they would undergo both capsule endoscopy and subsequent push enteroscopy. Results of capsule examinations were compared with push enteroscopy findings. Capsule endoscopy was performed with the Given M2A video capsule system. RESULTS: Twenty-one patients (12 women, 9 men, average age 61 years) were enrolled, all of whom completed the study. A bleeding site was found in 11 of 20 patients during capsule endoscopy. No additional intestinal diagnoses were made by enteroscopy. The yield of push enteroscopy in the evaluation of obscure bleeding was 30% (6/20), the yield of capsule endoscopy 55% (11/20). This difference did not reach statistical significance (p = 0.0625). Capsule endoscopy found a distal source of bleeding in 5 of 14 patients who had normal push enteroscopic examinations. Patients preferred capsule endoscopy to enteroscopy. CONCLUSIONS: This pilot study demonstrates that capsule endoscopy provides excellent visualization of the small intestine, is well tolerated by patients, and is safe. Capsule endoscopy identified small intestinal bleeding sites beyond the range of push enteroscopy.     

Jejunal diverticular bleeding diagnosed by double-balloon enteroscopy: a case report and review of literatures]

Jejunal diverticula is a rare disease and an unusual cause of obscure gastrointestinal hemorrhage. Obscure gasterointestinal bleeding is difficult to treat because the bleeding site cannot be identified by routine endoscopy and contrast studies. A wireless capsule endoscopy is not invasive and can visualize the entire small bowel. However, this method has limitations of incapability of taking biopsies and performing endoscopic interventions such as polypectomy or stent insertion. The double-balloon enteroscopy is being used frequently for the diagnosis and management of various small bowel diseases. We report a case of proximal jejunal diverticular bleeding diagnosed by double-balloon enteroscopy and treated with angiographic embolization.     

Ileus secondary to wireless capsule enteroscopy

Wireless capsule enteroscopy, being a novel, painless investigative technique, is reported to be significantly superior to push enteroscopy in its ability to find bleeding abnormalities in the small intestine. Here we report a case of acute jejunal obstruction following wireless capsule endoscopy. The patient had a 1-month history of gastrointestinal bleeding of unknown source. Further evaluation including gastroscopy and colonoscopy, angiography and computed tomography (angio–CT), and radio-labeled erythrocytes scan failed to reveal a source of bleeding. Therefore, wireless capsule enteroscopy was performed. Before capsule endoscopy, there was no clinical or imaging evidence of strictures or stenosis. At readmission it could be shown that there were two inflamed strictures of the small intestine. The capsule was detected at a stricture of the small intestine detected by abdominal ultrasonography and conventional computed tomography. The patient underwent a medical treatment with steroidal and other anti-inflammatory drugs for a total of 23 days and was discharged without complaints. Acute laparotomy after readmission with jejunal ileus proofed the capsule occluding two highly inflamed jejunal stenosis caused by Crohn disease. The present case demonstrates the potential for complications when wireless capsule enteroscopy is performed in the presence of intestinal strictures. Any history of inflammatory bowel disease, abdominal irradiation, cancer, obstruction, and abdominal surgery must be elicited in detail and may exclude the use of wireless capsule enteroscopy.     

胶囊内镜在小肠疾病诊断中的应用研究

目的探讨胶囊内镜在小肠疾病诊断中的应用价值和安全性。方法回顾分析采用OMOM胶囊内镜检查的216例患者,其中不明原因消化道出血43例,慢性腹痛72例,慢性腹泻54例,腹部不适20例,体检27例,对诊断结果进行分析。结果对出血性病变的阳性诊断率为69.8%,显著高于对慢性腹痛、慢性腹泻及腹部不适的阳性诊断率(P0.05)。结论胶囊内镜是不明原因消化道出血的首选检查方法,安全性高,耐受性好,在小肠疾病诊断中具有重要价值。     

双气囊小肠镜与胶囊内镜诊断小肠出血病因比较

目的比较双气囊小肠镜和胶囊内镜在小肠出血中的诊断准确率和实用价值。方法24例原因不明的可疑小肠出血患者分别接受双气囊小肠镜和胶囊内镜检查。双气囊小肠镜首选进镜方式分为经口或经肛2种，首选方式检查后未发现病灶者，日后改换进镜方式再行检查。胶囊内镜采用以色列GIVEN公司产品。2种检查方法分别由专门医师独立操作并诊断，最后进行汇总比较。结果24例患者中21例通过小肠镜检查发现病灶，总检出率为87．5％。24例患者行胶囊内镜检查后，有阳性发现者11例(45．8％)，另13例无异常发现。双气囊小肠镜检查发现的阳性病灶均经活检病理和手术探查证实，其病因诊断准确率为87．5％，胶囊内镜诊断准确率为25％。在耐受性评估方面，胶囊内镜和全麻下经口进镜的耐受性最佳，以后依次为非麻醉经肛方式和非麻醉经口方式。所有小肠镜和胶囊内镜检查者中未见操作相关的严重不良反应。结论①经口和经肛方式结合能使双气囊小肠镜完成对全小肠的检查。②双气囊小肠镜在不明原因小肠出血的病因诊断方面明显优于胶囊内镜检查。③胶囊内镜在小肠多节段病变和长段病变的诊断上仍有一定价值。④胶囊内镜和全麻下经口双气囊小肠镜检查是一项易为患者接受的、安全的检查方法。     

Capsule endoscopy versus push enteroscopy in patients with occult gastrointestinal bleeding

BACKGROUND: Wireless capsule endoscopy is a new method enabling non-invasive diagnostic endoscopy of the entire small intestine. In this study we prospectively examined the diagnostic precision of capsule endoscopy compared with push enteroscopy in patients with occult gastrointestinal bleeding. METHODS: Between July 2001 and October 2002 we examined 48 patients with suspected disorders of the small intestine using capsule endoscopy. 33 patients with obscure bleeding (19 men, 14 women, mean age 58 +/- 23 years) were prospectively examined using capsule endoscopy and push enteroscopy. RESULTS: On average, the patients had been suffering from chronic gastrointestinal bleeding for 30 +/- 36 (1-120) months. The lowest haemoglobin level was 6.5 +/- 1.6 g/dl (2.3-9.6) and on average 9 +/- 10 (0-50) blood units were transfused. Each patient underwent 4 +/- 2 (1-10) hospitalisations, with a mean 9 +/- 4 (5-17) diagnostic procedures before capsule endoscopy was used. Definitive bleeding sites were diagnosed by push enteroscopy in 7 patients (angiodysplasia [n = 5], ulcers [n = 1], multiple jejunal diverticula [n = 1]). Capsule endoscopy showed a bleeding source in 25 cases (76 %) (angiodysplasias [n = 15], Meckel's diverticulum [n = 1], ulcers [n = 7], ileum diverticulosis [n = 1], B-cell lymphoma [n = 1]). Push enteroscopy localised an additional bleeding source in comparison with capsule endoscopy (multiple jejunal diverticula) in one patient. Both methods of examination were safe and showed no complications. DISCUSSION: The present study shows that capsule endoscopy had the highest diagnostic yield and was superior to push enteroscopy in patients with chronic gastrointestinal bleeding. By using the capsule at an early stage the subsequent therapeutic procedure could be considerably shortened and diagnostic processes could possibly be optimised.     

Alcohol consumption is associated with an increased risk of erosive esophagitis and Barrett's epithelium in Japanese men

Background

The precise role of capsule endoscopy in the diagnostic algorithm of obscure gastrointestinal bleeding has yet to be determined. Despite the higher diagnostic yield of capsule endoscopy, the actual impact on clinical outcome remains poorly defined. The aim of this study was to evaluate the follow-up results of patients with obscure gastrointestinal bleeding to determine which management strategies after capsule endoscopy reduced rebleeding.

Methods

All patients in whom the cause of obscure gastrointestinal bleeding was investigated between May 2004 and March 2007 were studied retrospectively. We evaluated the clinical outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy using the rebleeding rate as the primary outcome.

Results

Seventy-seven patients with obscure gastrointestinal bleeding underwent capsule endoscopy. Capsule endoscopy identified clinically significant findings that were thought to be the sources of obscure gastrointestinal bleeding in 58.4% of the patients. The overall rebleeding rate was 36.4%. The rebleeding rate was significantly higher among patients with insignificant findings than among those with significant findings (p = 0.036). Among the patients in whom capsule endoscopy produced significant findings, the rebleeding rate of the patients who underwent therapeutic interventions was significantly lower than that in those who did not undergo intervention (9.5% vs 40.0%, p = 0.046).

Conclusion

Follow-up and further aggressive interventions are necessary for patients with obscure gastrointestinal bleeding and significant capsule endoscopy findings to reduce the chance of rebleeding.