Arthur D. Shiff

A Meta-Analysis of the Yield of Capsule Endoscopy Compared to Other Diagnostic Modalities in Patients with Obscure Gastrointestinal Bleeding

OBJECTIVES:Due to its superior ability to examine the entire small bowel mucosa, capsule endoscopy (CE) has broadened the diagnostic evaluation of patients with obscure gastrointestinal bleeding (OGIB). Published studies have revealed a numerically superior performance of CE in determining a source of OGIB compared with other modalities, but due to small sample sizes, the overall magnitude of benefit is unknown. Additionally, the types of lesions more likely to be found by CE versus alternate modalities are also unknown. The aim of this study was to evaluate the yield of small bowel findings with CE in patients with OGIB compared to other modalities using meta-analysis.METHODS:We performed a recursive literature search of prospective studies comparing the yield of CE to other modalities in patients with OGIB. Data on yield and types of lesions identified 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.RESULTS:A total of 14 studies (n = 396) compared the yield of CE with push enteroscopy for OGIB. The yield for CE and push enteroscopy was 63% and 28%, respectively (IY = 35%, p < 0.00001, 95% CI = 26–43%) and for clinically significant findings (n = 376) was 56% and 26%, respectively (IY = 30%, p < 0.00001, 95% CI = 21–38%). Three studies (n = 88) compared the yield of CE to small bowel barium radiography. The yield for CE and small bowel barium radiography for any finding was 67% and 8%, respectively (IY = 59%, p < 0.00001, 95% CI = 48–70%) and for clinically significant findings was 42% and 6%, respectively (IY = 36%, p < 0.00001, 95% CI = 25–48%). Number needed to test (NNT) to yield one additional clinically significant finding with CE over either modality was 3 (95% CI = 2–4). One study each compared the yield of significant findings on CE to intraoperative enteroscopy (n = 42, IY = 0%, p = 1.0, 95% CI =−16% to 16%), computed tomography enteroclysis (n = 8, IY = 38%, p = 0.08, 95% CI =−4% to 79%), mesenteric angiogram (n = 17, IY =−6%, p = 0.73, 95% CI =−39% to 28%), and small bowel magnetic resonance imaging (n = 14, IY = 36%, p = 0.007, 95% CI = 10–62%). Ten of the 14 trials comparing CE with push enteroscopy classified the types of lesions found on examination. CE had a 36% yield for vascular lesions versus 20% for push enteroscopy, with an IY of 16% (p < 0.00001, 95% CI = 9–23%). Inflammatory lesions were also found more often in CE (11%) than in push enteroscopy (2%), with an IY of 9% (p = 0.0001, 95% CI = 5–13%). There was no significant difference in the yield of tumors or “other” findings between CE and push enteroscopy.CONCLUSIONS:CE is superior to push enteroscopy and small bowel barium radiography for diagnosing clinically significant small bowel pathology in patients with OGIB. In study populations, the IY of CE over push enteroscopy and small bowel barium radiography for clinically significant findings is ≥30% with an NNT of 3, primarily due to visualization of additional vascular and inflammatory lesions by CE.

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 Crohns 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 has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohn's disease: a meta-analysis

OBJECTIVES:Capsule endoscopy (CE) has demonstrated superior performance compared with other modalities in its ability to detect early small-bowel (SB) Crohns disease (CD), especially when ileoscopy is negative or unsuccessful. The aim of this study was to evaluate the diagnostic yield of CE compared with other modalities in patients with suspected and established CD using a meta-analysis.METHODS:A thorough literature search for prospective studies comparing the diagnostic yield of CE with other modalities in patients with CD was undertaken. Other modalities included push enteroscopy (PE), colonoscopy with ileoscopy (C+IL), SB radiography (SBR), computed tomography enterography (CTE), and magnetic resonance enterography (MRE). Data on diagnostic yield among various modalities were extracted, pooled, and analyzed. Data on patients with suspected and established CD were analyzed separately. Weighted incremental yield (IYW) (diagnostic yield of CE−diagnostic yield of comparative modality) and 95% confidence intervals (CIs) of CE over comparative modalities were calculated.RESULTS:A total of 12 trials (n=428) compared the yield of CE with SBR in patients with CD. Eight trials (n=236) compared CE with C+IL, four trials (n=119) compared CE with CTE, two trials (n=102) compared CE with PE, and four trials (n=123) compared CE with MRE. For the suspected CD subgroup, several comparisons met statistical significance. Yields in this subgroup were CE vs. SBR: 52 vs. 16% (IYw=32%, P<0.0001, 95% CI=16–48%), CE vs. CTE: 68 vs. 21% (IYw=47%, P<0.00001, 95% CI=31–63%), and CE vs. C+IL: 47 vs. 25% (IYw=22%, P=0.009, 95% CI=5–39%). Statistically significant yields for CE vs. an alternate diagnostic modality in established CD patients were seen in CE vs. PE: 66 vs. 9% (IYw=57%, P<0.00001, 95% CI=43–71%), CE vs. SBR: 71 vs. 36% (IYw=38%, P<0.00001, 95% CI=22–54%), and in CE vs. CTE: 71 vs. 39% (IYw=32%, P=<0.0001, 95% CI=16–47%).CONCLUSIONS:Our meta-analysis demonstrates that CE is superior to SBR, CTE, and C+IL in the evaluation of suspected CD patients. CE is also a more effective diagnostic tool in established CD patients compared with SBR, CTE, and PE.

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.

Yield of repeat wireless video capsule endoscopy in patients with obscure gastrointestinal bleeding.

PURPOSE:Capsule endoscopy (CE) has been shown to have a high diagnostic yield in patients with obscure gastrointestinal bleeding (OGIB). It is not known if repeating CE improves diagnostic yield or changes patient management when the initial CE is negative or nondiagnostic. The aims of this study are (1) to understand the reasons for repeat CE, (2) to determine the diagnostic yield of repeat CE, and (3) to establish if findings on repeat CE resulted in a change in patient management.METHODS:Between August 2001 and October 2003, we performed 391 capsule studies. Of these, 24 were repeat studies in patients with OGIB. We retrospectively reviewed the charts of these 24 patients.RESULTS:The reasons for repeat CE were: recurrent gastrointestinal bleeding (13), limited visualization on first exam due to poor prep or blood (10), complication (1) (capsule impaction at cricopharyngeus). Eighteen of 24 (75%) repeat capsule studies revealed additional findings (7 arteriovenous malformations, 2 gastropathy, 2 erosions, 2 masses, 1 ulcer, 2 red spots, 1 linear streak, 1 erythema). These findings led to changes in patient management in 15 of the 24 (62.5%) cases.CONCLUSIONS:Indications for repeat CE most commonly include recurrent gastrointestinal bleeding and limited visualization on initial study. Repeat CE results in a high yield of new findings that lead to changes in patient management. Repeat CE should be considered in patients with persistent OGIB when the initial study is negative or inconclusive.

Capsule Endoscopy in Patients with Implantable Electromedical Devices is Safe

Background and Study Aims. The presence of an implantable electromechanical cardiac device (IED) has long been considered a relative contraindication to the performance of video capsule endoscopy (CE). The primary aim of this study was to evaluate the safety of CE in patients with IEDs. A secondary purpose was to determine whether IEDs have any impact on images captured by CE. Patients and Methods. A retrospective chart review of all patients who had a capsule endoscopy at Mayo Clinic in Scottsdale, AZ, USA, or Rochester, MN, USA, (January 2002 to June 2010) was performed to identify CE studies done on patients with IEDs. One hundred and eighteen capsule studies performed in 108 patients with IEDs were identified and reviewed for demographic data, method of preparation, and study data. Results. The most common indications for CE were obscure gastrointestinal bleeding (77%), anemia (14%), abdominal pain (5%), celiac disease (2%), diarrhea (1%), and Crohns disease (1%). Postprocedure assessments did not reveal any detectable alteration on the function of the IED. One patient with an ICD had a 25-minute loss of capsule imaging due to recorder defect. Two patients with LVADs had interference with capsule image acquisition. Conclusions. CE did not interfere with IED function, including PM, ICD, and/or LVAD and thus appears safe. Additionally, PM and ICD do not appear to interfere with image acquisition but LVAD may interfere with capsule images and require that capsule leads be positioned as far away as possible from the IED to assure reliable image acquisition.

Esophageal melanocytosis in the setting of Addison's disease

Melanocytosis of the digestive tract is defined as the presence of melanocytes at the interface between the epithelium and the lamina propria, without evidence of cytologic or architectural atypia. Esophageal melanocytosis is rarely identified endoscopically. This report describes a case of esophageal melanocytosis in a patient with known Addison’s disease. Esophageal melanocytosis is rare and this case suggests the possibility of a relationship to Addison’s disease.

Thirty years of overt, obscure GI bleeding solved by modern technology

of ampullary tumors: 12-year review of 21 cases. Surg Endosc 2009;23: 45-9. 4. Adler DG, Qureshi W, Davila R, et al. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2006;64:849-54. 5. Han J, Kim MH. Endoscopic papillectomy for adenomas of the major duodenal papilla (with video). Gastrointest Endosc 2006;63:292-301. 6. Yamamoto H. Technology insight: endoscopic submucosal dissection of gastrointestinal neoplasms. Nat Clin Pract Gastroenterol Hepatol 2007;4:511-20. 7. Yamamoto H. Endoscopic submucosal dissection of early cancers and large flat adenomas. Clin Gastroenterol Hepatol 2005;3(Suppl 1): S74-6. 8. Yamamoto H, Yube T, Isoda N, et al. A novel method of endoscopic mucosal resection using sodium hyaluronate. Gastrointest Endosc 1999;50:251-6. 9. Zadorova Z, Dvofak M, Hajer J. Endoscopic therapy of benign tumors of the papilla of Vater. Endoscopy 2001;33:345-7. 10. Eswaran SL, Sanders M, Bernadino KP, et al. Success and complications of endoscopic removal of giant duodenal and ampullary polyps: a comparative series. Gastrointest Endosc 2006;64:925-32. 11. Yoon YS, Kim SW, Park SJ, et al. Clinicopathologic analysis of early ampullary cancers with a focus on the feasibility of ampullectomy. Ann Surg 2005;242:92-100. 12. Yamamoto H, Kawata H, Sunada K, et al. Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 2003;35: 690-4.

False-positive wireless video capsule secondary to performing a simultaneous sigmoidoscopy.

Erratum: False-Positive Wireless Video Capsule Secondary to Performing a Simultaneous Sigmoidoscopy

Response to doherty, moss, and cheifetz

To the Editor: We thank Doherty et al. (1) for their interest in our article as well as for their valuable comments. The data in our meta-analysis (2) and our conclusions were based on prior studies included in the analysis. We realize that many of the studies had limitations that would influence the interpretation of our data. For example, it is clear that false-positive capsule endoscopy (CE) findings as well as selection bias in the published studies we analyzed are among the limitations. In the only prospective, blinded study comparing CE, computed tomography (CT) enterography, small bowel radiography and colonoscopy, the sensitivity of CE and CT enterography was identical. However, the specificity of CE was significantly lower than other tests (3) possibly indicating higher false-positive rate. We thoroughly agree with Dougherty et al. (1) that a standardized grading scale for CE findings is indeed important and should be applied to future studies to improve specificity and overall diagnostic accuracy of CE in the diagnosis of small bowel inflammation and suspected Crohns disease.