A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohn's disease

OBJECTIVES: Capsule endoscopy (CE) allows for direct evaluation of the small bowel mucosa in patients with Crohn's disease (CD). A number of studies have revealed significantly improved yield for CE over other modalities for the diagnosis of CD, but as sample sizes have been small, the true degree of benefit is uncertain. Additionally, it is not clear whether patients with a suspected initial presentation of CD and those with suspected recurrent disease are equally likely to benefit from CE. The aim of this study was to evaluate the yield of CE compared with other modalities in symptomatic patients with suspected or established CD using meta-analysis. METHODS: We performed a recursive literature search of prospective studies comparing the yield of CE to other modalities in patients with suspected or established CD. Data on yield among various modalities were extracted, pooled, and analyzed. Incremental yield (IY) (yield of CE--yield of comparative modality) and 95% confidence intervals (95% CI) of CE over comparative modalities were calculated. Subanalyses of patients with a suspected initial presentation of CD and those with suspected recurrent disease were also performed. RESULTS: Nine studies (n = 250) compared the yield of CE with small bowel barium radiography for the diagnosis of CD. The yield for CE versus barium radiography for all patients was 63% and 23%, respectively (IY = 40%, p < 0.001, 95% CI = 28-51%). Four trials compared the yield of CE to colonoscopy with ileoscopy (n = 114). The yield for CE versus ileoscopy for all patients was 61% and 46%, respectively (IY = 15%, p= 0.02, 95% CI = 2-27%). Three studies compared the yield of CE to computed tomography (CT) enterography/CT enteroclysis (n = 93). The yield for CE versus CT for all patients was 69% and 30%, respectively (IY = 38%, p= 0.001, 95% CI = 15-60%). Two trials compared CE to push enteroscopy (IY = 38%, p < 0.001, 95% CI = 26-50%) and one trial compared CE to small bowel magnetic resonance imaging (MRI) (IY = 22%, p= 0.16, 95% CI =-9% to 53%). Subanalysis of patients with a suspected initial presentation of CD showed no statistically significant difference between the yield of CE and barium radiography (p= 0.09), colonoscopy with ileoscopy (p= 0.48), CT enterography (p= 0.07), or push enteroscopy (p= 0.51). Subanalysis of patients with established CD with suspected small bowel recurrence revealed a statistically significant difference in yield in favor of CE compared with all other modalities (barium radiography (p < 0.001), colonoscopy with ileoscopy (p= 0.002), CT enterography (p < 0.001), and push enteroscopy (p < 0.001)). CONCLUSIONS: In study populations, CE is superior to all other modalities for diagnosing non-stricturing small bowel CD, with a number needed to test (NNT) of 3 to yield one additional diagnosis of CD over small bowel barium radiography and NNT = 7 over colonoscopy with ileoscopy. These results are due to a highly significant IY with CE over all other modalities in patients with established non-stricturing CD being evaluated for a small bowel recurrence. While there was no significant difference seen between CE and alternate modalities for diagnosing small bowel CD in patients with a suspected initial presentation of CD, the trend toward significance for a number of modalities suggests the possibility of a type II error. Larger studies are needed to better establish the role of CE for diagnosing small bowel CD in patients with a suspected initial presentation of CD.     

Capsule endoscopy versus computed tomographic or standard angiography for the diagnosis of obscure gastrointestinal bleeding

BACKGROUND AND AIMS: Capsule endoscopy (CE) is superior to push enteroscopy and small bowel barium radiography in detecting the source of obscure GI bleeding. We now compared whether CE has a superior diagnostic yield than CT angiography (CTA) or standard mesenteric angiography (ANGIO) in patients with obscure GI bleeding. METHODS: From June 2004 to October 2005, consecutive patients admitted for OGIB underwent both CTA and ANGIO, followed by CE, performed blindly by independent examiners within the next 7 days. The primary end point of the study was the diagnostic yield for each technique, defined as the frequency of detection of lesions with a high probability of bleeding. RESULTS: Twenty-eight patients (16 men and 12 women, mean age 74 +/- 2 yr) with OGIB (overt bleeding in 20 cases and chronic occult in 8) were prospectively evaluated. CTA or standard angiography could be performed in 25 of 28 patients (applicability 86%), because of contrast allergy (1 patient) and chronic renal failure (2 patients). A source of bleeding was detected by CE in a greater proportion of patients, 72% (18 of 25, 95% CI 50.6-87.9%), than CTA, 24% (6 of 25, 95% CI 9.4-45.1%, P= 0.005 vs CE), or ANGIO, 56% (14 of 25, 95% CI 34.9-75.6%, P= NS). Similarly, CE was able to diagnose 100% of patients diagnosed by CTA and 86% of patients diagnosed by ANGIO. Moreover, CE was positive in 12 of 19 (63%) negative cases on CTA and in 6 of 11 (55%) negative cases on ANGIO. As a result of the CE findings, therapeutic intervention was undertaken in 9 of 19 (47%) patients with positive results. CONCLUSION: CE detects more lesions than CTA or standard mesenteric angiography in patients with obscure GI bleeding and has a therapeutic impact in almost half of the patients with positive findings.     

Obscure gastrointestinal bleeding: role of videocapsule and double-balloon enteroscopy

Capsule endoscopy (CE), which allows the non-invasive visualisation of mucosa throughout the entire small bowel, has revolutionised the exploration of small-bowel diseases, and particularly the evaluation of obscure gastrointestinal bleeding (OGIB) after a negative initial evaluation, including gastroscopy and colonoscopy. CE has a high negative predictive value and a higher diagnostic yield than all other modalities, such as radiology (small-bowel X-rays or computed tomography scan) or push enteroscopy. CE may be the preferred initial diagnostic choice in OGIB because of its non-invasive quality and better tolerance. Double-balloon enteroscopy, also known as push-and-pull enteroscopy, has recently been developed. It has made it possible not only to explore the small bowel but also to carry out therapeutic interventions deep in the small bowel without the need for surgical laparotomy. This exploration should be considered as a second-line exploration for OGIB in patients with a positive finding on CE requiring endoscopic follow-up for histology or intervention, and in patients in whom suspicion of a small-bowel lesion is high despite a negative CE.     

Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis

BACKGROUND & AIMS: The aim of this study was to compare the diagnostic yield of capsule endoscopy (CE) with double-balloon enteroscopy (DBE) in small-bowel (SB) disease using meta-analysis. METHODS: We performed a search of studies comparing CE with DBE in SB disease. Data on diagnostic yield of CE and DBE were extracted, pooled, and analyzed. The weighted incremental yield (IY(W)) (yield of CE--yield of DBE) of CE over DBE and 95% confidence intervals (95% CIs) for pooled data were calculated using a fixed-effect model (FEM) for analyses without, and a random-effect model (REM) for analyses with, significant heterogeneity. RESULTS: Eleven studies compared CE and DBE; the pooled overall yield for CE and DBE was 60% (n = 397) and 57% (n = 360), respectively (IY(W), 3%; 95% CI, -4% to 10%; P = .42; FEM). Ten studies reported vascular findings; the pooled yield for CE and DBE was 24% (n = 371) and 24% (n = 364), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .88; REM). Nine studies reported inflammatory findings; the pooled yield for CE and DBE was 18% (n = 343) and 16% (n = 336), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .89; FEM). Nine studies reported polyps/tumors; the pooled yield for CE and DBE was 11% (n = 343) and 11% (n = 336), respectively (IY(W), -1%; 95% CI, -5% to 4%; P = .76; FEM). CONCLUSIONS: CE and DBE have comparable diagnostic yield in SB disease, including obscure gastrointestinal bleeding. CE should be the initial diagnostic test because of its noninvasive quality, tolerance, ability to view the entire SB, and for determining the initial route of DBE. Because of its therapeutic capabilities, DBE may be indicated in patients with a positive finding on CE requiring a biopsy or therapeutic intervention, if suspicion for a SB lesion is high despite a negative CE, and in patients with active bleeding.     

Push enteroscopy in the era of capsule endoscopy

GOALS: To evaluate the diagnostic yield of push enteroscopy in relation to indication and compare the yield in patients who had capsule endoscopy followed by push enteroscopy against capsule endoscopy naive patients. BACKGROUND: With the advent of capsule endoscopy the role of push enteroscopy needs to be reevaluated. STUDY: Patients who underwent push enteroscopy from January 2002 to May 2006 were included. RESULTS: One hundred fifty-five patients underwent push enteroscopy: 93 females, average age 55 years. There were 74 cases where both push enteroscopy (PE) and capsule endoscopy (CE) were performed. Indications for PE were iron deficiency anemia (n=51), overt bleeding (n=31), suspected celiac disease (n=32), refractory celiac disease (n=19), assessment for Crohn's disease (n=10), and miscellaneous (n=12). In 148 patients, an average length of 70 cm of small bowel was examined (range 30 to 130 cm). PE was unsuccessful in 7 patients due to anatomic strictures or patient distress. The overall diagnostic yield was 30% with the highest yield in overt bleeding when compared with other subgroups (P<0.001). Nine percent of lesions were within the reach of a standard endoscope. Comparison of the diagnostic yield in patients who had CE followed by PE against CE naive patients was 41% versus 47%, respectively (P<1). There were no cases where push enteroscopy recognized a lesion that had not been already detected by capsule endoscopy. CONCLUSIONS: Push enteroscopy has the greatest diagnostic yield in patients with overt bleeding when compared with other referral indications. PE should be used as an adjuvant to CE for therapeutic intervention.     

Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis

Background and Aim: Uncertainty remains about the best test to evaluate patients with obscure gastrointestinal bleeding (OGIB). Previous meta‐analyses demonstrated similar diagnostic yields with capsule endoscopy (CE) and double balloon enteroscopy (DBE) but relied primarily on data from abstracts and were not limited to bleeding patients. Many studies have since been published. Therefore, we performed a new meta‐analysis comparing CE and DBE focused specifically on OGIB. Methods: A comprehensive literature search was performed of comparative studies using both CE and DBE in patients with OGIB. Data were extracted and analyzed to determine the weighted pooled diagnostic yields of each method and the odds ratio for the successful localization of a bleeding source. Results: Ten eligible studies were identified. The pooled diagnostic yield for CE was 62% (95% confidence interval [CI] 47.3–76.1) and for DBE was 56% (95% CI 48.9–62.1), with an odds ratio for CE compared with DBE of 1.39 (95% CI 0.88–2.20; P = 0.16). Subgroup analysis demonstrated the yield for DBE performed after a previously positive CE was 75.0% (95% CI 60.1–90.0), with the odds ratio for successful diagnosis with DBE after a positive CE compared with DBE in all patients of 1.79 (95% CI 1.09–2.96; P = 0.02). In contrast, the yield for DBE after a previously negative CE was only 27.5% (95% CI 16.7–37.8). Conclusions: Capsule endoscopy and double balloon enteroscopy provide similar diagnostic yields in patients with OGIB. However, the diagnostic yield of DBE is significantly higher when performed in patients with a positive CE.     

Double Balloon Enteroscopy Detects Small Bowel Mass Lesions Missed by Capsule Endoscopy

BACKGROUND: Small bowel mass lesions (SBML) are a relatively common cause of obscure gastrointestinal bleeding (OGIB). Their detection has been limited by the inability to endoscopically examine the entire small intestine. This has changed with the introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE) into clinical practice. STUDY AIM: To evaluate the detection of SBML by DBE and CE in patients with OGIB who were found to have SBML by DBE and underwent both procedures. METHODS: A retrospective review of a prospectively collected database of all patients undergoing DBE for OGIB at seven North American tertiary centers was performed. Those patients who were found to have SBML as a cause of their OGIB were further analyzed. RESULTS: During an 18 month period, 183 patients underwent DBE for OGIB. A small bowel mass lesion was identified in 18 patients. Of these, 15 patients had prior CE. Capsule endoscopy identified the mass lesion in five patients; fresh luminal blood with no underlying lesion in seven patients, and non-specific erythema in three patients. Capsule endoscopy failed to identify all four cases of primary small bowel adenocarcinoma. CONCLUSIONS: Double balloon enteroscopy detects small bowel mass lesions responsible for OGIB that are missed by CE. Additional endoscopic evaluation of the small bowel by DBE or intraoperative enteroscopy should be performed in patients with ongoing OGIB and negative or non-specific findings on CE.     

Capsule endoscopy and single-balloon enteroscopy in small bowel diseases: Competing or complementary?

AIM To evaluate diagnostic yields of capsule endoscopy(CE) and/or single-balloon enteroscopy(SBE) in patients with suspected small bowel diseases.METHODS Were trospectively analyzed 700 patients with suspected small bowel diseases from September 2010 to March 2016. CE, SBE, or SBE with prior CE was performed in 401, 353, and 47 patients, respectively. Data from clinical and endoscopy records were collected for analysis. Indications, procedure times, diagnostic yields, and complications were summarized and evaluated.RESULTS The overall diagnostic yield for the CE group was 57.6%. The diagnostic yield of CE in patients with obscure gastroin testinal bleeding(OGIB) was significantly greater than that in patients with no bleeding(70.5% vs 43.8%, P 0.01). The overall diagnostic yield of SBE was 69.7%. There was no difference in the diagnostic yield of SBE between patients with OGIB and those with no bleeding(72.5% vs 68.9%, P = 0.534). Forty-seven patients underwent CE prior to SBE. Among them, the diagnostic yield of SBE with positive findings on prior CE was 93.3%. In addition, SBE detected two cases with superficial ulcer and erosive lesions in the small bowel, which were missed by CE. However, one case with lymphoma and two with Crohn's disease were not confirmed by SBE. The rate of capsule retention was 2.0%. There were no significant complications during or after SBE examinations.CONCLUSION SBE is a safe and effective technique for diagnosing small bowel diseases. SBE with prior CE seemed to improve the diagnostic yield of small bowel diseases.     

Long-term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy

BACKGROUND AND AIMS: Capsule endoscopy (CE) is one of the widely accepted investigations for obscure gastrointestinal bleeding (OGIB), but little is known about the impact of CE on the long-term outcome of patients with OGIB. We studied the long-term outcome of patients with OGIB after CE examination. PATIENTS AND METHODS: Forty-nine consecutive patients (45% men, mean age 58.3 yr) who underwent CE for OGIB were studied. The most clinically relevant finding that was related to bleeding was identified by CE. All patients were followed up for at least 12 months for clinical overt and occult bleeding. RESULTS: The median follow-up was 19 months (range 12 to 31). Possible bleeding lesions were detected by CE in 31 (63.3%) patients, and 15 (30.6%) patients, underwent further interventions including laparotomy and push enteroscopy. The overall long-term rebleeding rate in this cohort was 32.7%. The cumulative rebleeding rate was significantly lower in patients with a negative CE (5.6%) than in patients with a positive CE (48.4%, p=0.03 log-rank test). The sensitivity and negative predictive value of CE in predicting rebleeding were 93.8% and 94.4%, respectively. CONCLUSIONS: Patients with OGIB and negative CE had a very low rebleeding rate, and further invasive investigations can be deferred.     

A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding

OBJECTIVES: Capsule endoscopy (CE) has revolutionized the evaluation of obscure gastrointestinal bleeding (OGIB) but published literature is limited to small series with heterogeneous indications. The aim of this study was to determine the findings and the diagnostic yield of CE in a large series of patients with overt and occult OGIB. METHODS: Data on 260 patients who underwent CE for overt (N = 126) or occult (N = 134) OGIB were obtained by retrospective chart review and review of an internal database of CE patients and findings. RESULTS: Visualization of the entire small bowel was achieved in 74%. The majority of exams (66%) were rated as having a good or excellent prep. Clinically significant positive findings occurred in 53%. The yield of CE in the obscure-overt group was greater than in the obscure-occult group (60%vs 46%, P= 0.03). Small bowel angioectasias were the most common finding, comprising over 60% of clinically significant lesions. The mean follow-up was 9.6 months, and there were significant reductions in hospitalizations, additional tests/procedures, and units of blood transfused after CE. Both before and after CE, patients in the overt group had more significant GI bleeding than patients in the occult group. Complications occurred in five (1.9%) cases: nonnatural excretion (four) and CE impaction at cricopharyngeus (one). CONCLUSIONS: The yield of clinically important findings on CE in patients with OGIB is 53% and is greater in patients with obscure-overt than obscure-occult GI bleeding. Angioectasias account for the majority of significant lesions in both groups. Compared with pre-CE, patients had clinical improvement post-CE in medical interventions for OGIB. Complications of CE occur in less than 2% of cases.     

Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature

Iron deficiency anemia (IDA) is common and often under recognized problem in the elderly. It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract. Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel (SB). Capsule endoscopy (CE) provides direct visualization of entire SB mucosa, which was not possible before. It is superior to push enteroscopy, enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA. Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA. The diagnostic yield of CE for IDA progressively increases with advancing age, and is highest among patients over 85 years of age. Balloon assisted enteroscopy is used to treat the lesions seen on CE. CE has some limitations mainly lack of therapeutic capability, inability to provide precise location of the lesion and false positive results. Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.     

Concordancia diagnóstica entre la videocápsula endoscópica y enteroscopia mono y de doble balón en la hemorragia de intestino delgado en un hospital de alta complejidad en Bogotá, Colombia

IntroductionVideo capsule endoscopy and balloon-assisted enteroscopy are complementary diagnostic methods in the study of small bowel bleeding, and different factors can affect their diagnostic yield.AimsTo define the level of agreement between video capsule endoscopy and enteroscopy in small bowel bleeding, according to the type of lesion, in a cohort of patients at a tertiary care referral center.Materials and methodsA retrospective study was conducted that included 428 capsule endoscopies performed within the time frame of 2011 and 2019 at our healthcare institution. Seventy-four video capsule endoscopies, followed by enteroscopy, in 71 patients suspected of presenting with small bowel bleeding, were analyzed.ResultsMean patient age was 63.9 ± 13.5 years and 42 patients were women. The two diagnostic procedures were performed. Overall diagnostic yield of positive findings between video capsule endoscopy and enteroscopy was 86.5% vs. 58.1%, respectively (p = 0.0527). Agreement between video capsule endoscopy and enteroscopy for positive pathologic findings was weak (Ik = 0.17, 95% CI: -0.0097-0.3543), but according to lesion type, it was good for inflammatory lesions (Ik = 0.71, 95% CI: 0.5182-0.9119) and moderate for angiectasias (Ik = 0.45, 95% CI: 0.2469-0.6538) and tumors (Ik = 0.40, 95% CI: 0.1217-0.6794). The results between the two methods differed in 38 patients (51.3%). There was complete intestinal capsule retention in one patient (1.4%) and active bleeding in 13 (17.6%).ConclusionsThe present study showed that the two techniques had a similar overall detection rate for small bowel lesions, but the type of lesion was the main factor that could modify diagnostic agreement.     

胶囊内镜在小肠疾病中的应用进展

胶囊内镜（CE）技术发展迅速,已成为一线小肠无创检查技术之一,目前已广泛用于不明原因消化道出血（OGIB）、炎症性肠病、小肠肿瘤、乳糜泻和腹痛等的诊断,其与双气囊小肠镜（DBE）联合应用可提高小肠疾病的诊疗水平。本文就CE在小肠疾病中的应用进展作一综述。     

Randomized controlled trial comparing outcomes of video capsule endoscopy with push enteroscopy in obscure gastrointestinal bleeding

BACKGROUND:

Optimal management of obscure gastrointestinal bleeding (OGIB) remains unclear.

OBJECTIVE:

To evaluate diagnostic yields and downstream clinical outcomes comparing video capsule endoscopy (VCE) with push enteroscopy (PE).

METHODS:

Patients with OGIB and negative esophagogastroduodenoscopies and colonoscopies were randomly assigned to VCE or PE and followed for 12 months. End points included diagnostic yield, acute or chronic bleeding, health resource utilization and crossovers.

RESULTS:

Data from 79 patients were analyzed (VCE n=40; PE n=39; 82.3% overt OGIB). VCE had greater diagnostic yield (72.5% versus 48.7%; P<0.05), especially in the distal small bowel (58% versus 13%; P<0.01). More VCE-identified lesions were rated possible or certain causes of bleeding (79.3% versus 35.0%; P<0.05). During follow-up, there were no differences in the rates of ongoing bleeding (acute [40.0% versus 38.5%; P not significant], chronic [32.5% versus 45.6%; P not significant]), nor in health resource utilization. Fewer VCE-first patients crossed over due to ongoing bleeding (22.5% versus 48.7%; P<0.05).

CONCLUSIONS:

A VCE-first approach had a significant diagnostic advantage over PE-first in patients with OGIB, especially with regard to detecting small bowel lesions, affecting clinical certainty and subsequent further small bowel investigations, with no subsequent differences in bleeding or resource utilization outcomes in follow-up. These findings question the clinical relevance of many of the discovered endoscopic lesions or the ability to treat most of these effectively over time. Improved prognostication of both patient characteristics and endoscopic lesion appearance with regard to bleeding behaviour, coupled with the impact of therapeutic deep enteroscopy, is now required using adapted, high-quality study methodologies.     

Yield,etiologies and outcomes of capsule endoscopy in Thai patients with obscure gastrointestinal bleeding

AIM: To investigate the yield, etiologies and impact of capsule endoscopy (CE) in Thai patients with obscure gastrointestinal bleeding (OGIB).METHODS: The present study is a retrospective cohort study. All patients with OGIB who underwent CE in Siriraj Hospital, Bangkok, Thailand during 2005-2009 were included in the study. All the patients’ medical records and results of the CE videos were reviewed. CE findings were classified as significant, suspicious/equivocal and negative. Sites of the lesions were located to duodenum, jejunum, jejunoileum, ileum and diffuse lesions by the localization device of the CE. Impact of CE on the patients’ management was defined by any investigation or treatment given to the patients that was more than an iron supplement or blood transfusion. Patients’ outcomes (rebleeding, persistent bleeding, anemia or requirement of blood transfusion) were collected from chart reviews and direct phone interviews with the patients.RESULTS: Overall, there were 103 patients with OGIB included in the study. Mean age of the patients was 64 ± 16 years (range 9-88 years) and 57 patients (55%) were male. Types of OGIB were overt in 80 (78%) and occult in 23 patients (22%). The median time interval of CE after onset of OGIB was 10 d (range 1-180 d). The median time of follow-up was 19 mo (range 1-54 mo). Capsules reached caecum in 77 patients (74%) and capsule retention was found in 1 patient (1%). The diagnostic yield of CE revealed significant lesions in 37 patients (36%), suspicious/equivocal lesions in 15 patients (15%) and 51 patients (49%) had negative CE result. Among the significant lesions, the bleeding etiologies were small bowel ulcers in 44%, angiodysplasia in 27%, small bowel tumor in 13%, miscellaneous in 8% and active bleeding without identifiable causes in 8%. Patients with small bowel ulcers were significantly associated with the use of non-steroidal anti-inflammatory drugs (48%, P = 0.034), while patients with small bowel tumors were more commonly female (86%, P = 0.043) compared to the other etiologies. The rate of rebleeding, persistent bleeding or anemia in patients with positive, equivocal and negative CE results were 5%, 0% and 18%, respectively (P = 0.078). All the 9 patients with rebleeding after negative CE were subsequently found to be from hematologic disorders (4), colonic diverticulosis (2), colonic Dieulafoy’s (1), hemorrhoid (1) and hemosuccus pancreaticus (1). Results of CE had a positive impact on the patients’ management in 35% of the patients whose results were positive, but none on the patients whose results were equivocal or negative CE (P < 0.001).CONCLUSION: In Thai OGIB patients, CE had low yield and small bowel ulcer was most common. Positive CE impacted managements and outcomes. Negative CE caused low rebleeding.     

The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use

Background We report our preliminary experience with the use of video capsule endoscopy (VCE) in 64 patients with obscure gastrointestinal bleeding (OGIB) and suspected small intestine disease.Methods To be eligible for VCE, patients had to have undergone upper endoscopy, small bowel series, and colonscopy without discovering any source of bleeding. To find the best timing to perform VCE, the patients were retrospectively divided in two groups of 32 cases each: group 1 with patients who had been submitted to VCE within 15 days from OGIB diagnosis, and group 2 with patients who had been submitted to VCE at least 15 days after OGIB diagnosis.Results Lesions were found by VCE in 29 (91%) in group 1: angioectasia-like lesions of the small bowel in 12, some erosions of the ileum without signs of bleeding in 14, a polyp with erosions in 1, and a bleeding site where the surgery showed a tumor of the ileum in 2 patients. In 2 cases, VCE missed showing two small tumors that were revealed by laparoscopy in 1 case and by push enteroscopy in the other. In group 2, lesions were found by VCE in 11 (34%): angioectasia-like lesions of the small bowel in 6, some erosions in 3, a short segmental stenosis in 1, and two polyps in 1. In 1 case, VCE missed showing a small polyp in the jejunum that was revealed by push enteroscopy. In none of these cases was a bleeding site identified. VCE was well tolerated and able to acquire good images in patients with OGIB. It showed lesions in 91% of the patients in group 1 and 34% of cases in group 2.Conclusions Our data suggest that the optimal timing to perform VCE is within a few days after the occurrence of bleeding, possibly within 2 weeks.     

胶囊内镜与单气囊小肠镜对可疑小肠疾病的诊断价值

目的比较胶囊内镜与单气囊小肠镜对小肠疾病的诊断价值。方法 2009年6月-2011年12月共有37例疑诊为小肠疾病的患者接受了胶囊内镜(CE)和单气囊小肠镜(SBE)检查。比较两种检查方法对小肠疾病的检出情况。结果在37例患者中,CE检查发现阳性病变28例,总体诊断率为75.68%(28/37),SBE检查发现阳性病变33例,总体诊断率为89.19%(33/37),两者之间差异无统计学意义(P=0.221)。CE和SBE检查结果不一致,CE检查阳性而SBE检查阴性3例,CE检查阴性而SBE检查阳性8例,CE和SBE检查均阴性1例。CE全小肠检查完成率为94.59%(35/37);SBE全小肠检查完成率为57.14%(4/7)。两种检查方法均未发生严重并发症。结论胶囊内镜和单气囊小肠镜对小肠疾病的诊断价值相当。     

A prospective comparative study of push and wireless-capsule enteroscopy in patients with obscure digestive bleeding

OBJECTIVES: To prospectively compare the global and specific diagnostic yields of push and wireless videocapsule enteroscopy for small bowel lesions in patients with obscure digestive bleeding after esogastroduodenoscopy and colonoscopy. METHODS: The patients studied had unexplained chronic iron-deficient anemia or digestive blood loss after routine investigations. Small bowel investigation was performed first with the wireless-capsule (M2A, Given Imaging) and then with the push-enteroscope (Olympus SIF100). RESULTS: Twenty-one patients were included in the protocol (14 females and 7 males), whose mean age was 60 years (range: 18 to 81). All patients had iron-deficient anemia with occult bleeding (n = 16) or overt bleeding (n = 5). A digestive lesion was observed in 14 of 21 cases (66%). Lesions were: esophageal varices (n = 2), reflux esophagitis (n = 1), upper gastrointestinal tract ulcerations (n = 9), intestinal angioectasia (n = 4), ileal varices (n = 1), cecal angioectasia (n = 1) and tumor-like angioma in the jejunum (n = 1). These 19 lesions were discovered by both methods in 10 cases (52%), by push-enteroscopy only in 6 (31%) and by wireless-capsule endoscopy only in 3 (17%). The global diagnostic yield was therefore slightly but not significantly higher for push wireless-capsule enteroscopy (61 vs 52%; NS) and the specific diagnostic yield was similar (20%). Interobserver agreement on the wireless-capsule recordings reached 85% for detection of findings. CONCLUSIONS: In patients with obscure digestive bleeding, no significant difference in diagnostic yield was evidenced between push and wireless-capsule endoscopy. The main advantage of the latter method versus the former was the detection of distal lesions in the small bowel. Wireless-capsule enteroscopy is mandatory for patients with active unexplained bleeding and negative push-enteroscopy, or for defining the extension of a disease involving, for instance, the presence of angioectasia.     

Role of capsule endoscopy in inflammatory bowel disease: where we are and where we are going

Capsule endoscopy (CE) is an innovative technological breakthrough that for the first time provides a noninvasive method to obtain high-resolution imaging of the entire small bowel. Since its recent inception, the diagnostic utility of CE has become well established for the evaluation of diverse ulcerative and inflammatory disorders of the jejunum and ileum. The incredible resolution of its lens (0.1 mm) detects focal villous edema or atrophy, denuded, as well as ulcerated mucosal lesions missed by other imaging techniques. CE has been shown by meta-analysis to be a more sensitive method to investigate patients for small bowel Crohn's disease, with an incremental yield above 30% versus other imaging modalities. In patients with indeterminate colitis, CE is useful in distinguishing between ulcerative and Crohn's colitis. Among patients with established Crohn's disease, CE may be employed to determine: (1) the extent and severity of small bowel involvement, (2) postoperative recurrence, (3) post-therapy mucosal healing, and (4) whether active small bowel inflammatory lesions exist in the clinical setting of functional bowel disorder. Complications are rare and include capsule retention at stricture sites. The new patency capsule can diminish the risk of the latter problem in at-risk patients. CE can also serve as a guide to sites that require biopsies or dilatation by push or double-balloon enteroscopy. However, other causes of small bowel lesions may mimic Crohn's disease. A standard terminology system has thus been developed, and a CE Crohn's disease severity scoring index is currently undergoing validation studies.     

A prospective comparison of capsule endoscopy and push enteroscopy in patients with GI bleeding of obscure origin

BACKGROUND: Capsule endoscopy is used to investigate the small bowel in patients with GI bleeding of obscure etiology. Capsule endoscopy was compared prospectively with push enteroscopy in 20 patients with GI hemorrhage. METHODS: Twenty patients (8 men, 12 women; mean age 65.5 years, range 38-80 years) were enrolled in the study. All had undergone non-diagnostic EGD, colonoscopy, and barium contrast radiography of the small bowel. All patients underwent capsule endoscopy followed by push enteroscopy. The physician performing the enteroscopy (senior endoscopist) interpreted the capsule endoscopy in an unblinded manner, while a second blinded reviewer (endoscopy fellow) interpreted the capsule endoscopy to establish interinterpreter reliability. RESULTS: There was complete agreement between the blinded and the unblinded physicians in 18 of 20 cases; minor disparities were noted in the remaining two cases. In the small bowel, capsule endoscopy identified positive findings in 14 (70%) patients, whereas, push enteroscopy identified positive findings in 5 (25%) patients. Despite these results, the findings were definitive in only 6 of the 20 patients by using capsule endoscopy, and in two of 20 patients with push enteroscopy. CONCLUSIONS: When strict standards of interpretation were used, capsule endoscopy resulted in more positive findings than push enteroscopy, but the number of definitive findings for both imaging methods was low. There was a high degree of reliability between a novice and an experienced endoscopist with respect to the interpretation of capsule endoscopy.