Aymer Postgate

Capsule endoscopy versus colonoscopy for the detection of polyps and cancer.

BACKGROUND An ingestible capsule consisting of an endoscope equipped with a video camera at both ends was designed to explore the colon. This study compared capsule endoscopy with optical colonoscopy for the detection of colorectal polyps and cancer. METHODS We performed a prospective, multicenter study comparing capsule endoscopy with optical colonoscopy (the standard for comparison) in a cohort of patients with known or suspected colonic disease for the detection of colorectal polyps or cancer. Patients underwent an adapted colon preparation, and colon cleanliness was graded from poor to excellent. We computed the sensitivity and specificity of capsule endoscopy for polyps, advanced adenoma, and cancer. RESULTS A total of 328 patients (mean age, 58.6 years) were included in the study. The capsule was excreted within 10 hours after ingestion and before the end of the lifetime of the battery in 92.8% of the patients. The sensitivity and specificity of capsule endoscopy for detecting polyps that were 6 mm in size or bigger were 64% (95% confidence interval [CI], 59 to 72) and 84% (95% CI, 81 to 87), respectively, and for detecting advanced adenoma, the sensitivity and specificity were 73% (95% CI, 61 to 83) and 79% (95% CI, 77 to 81), respectively. Of 19 cancers detected by colonoscopy, 14 were detected by capsule endoscopy (sensitivity, 74%; 95% CI, 52 to 88). For all lesions, the sensitivity of capsule endoscopy was higher in patients with good or excellent colon cleanliness than in those with fair or poor colon cleanliness. Mild-to-moderate adverse events were reported in 26 patients (7.9%) and were mostly related to the colon preparation. CONCLUSIONS The use of capsule endoscopy of the colon allows visualization of the colonic mucosa in most patients, but its sensitivity for detecting colonic lesions is low as compared with the use of optical colonoscopy. (ClinicalTrials.gov number, NCT00604162.)

Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy

BACKGROUND Capsule endoscopy (CE) is considered a first-line investigation for obscure GI bleeding (OGIB) and small-bowel polyp or tumor detection. The reliability of a negative CE in excluding gross small-bowel pathology remains unclear. New imaging modalities, such as double-balloon enteroscopy (DBE), CT enterography (CTE) or magnetic resonance enterography (MRE) now provide complementary roles to CE for these indications. OBJECTIVE We describe our experience of significant small-bowel pathology missed at CE in 5 patients. The lesions were subsequently detected by DBE, CTE, or MRE. DESIGN A retrospective case series. SETTING Single-center academic endoscopy unit in a tertiary-referral hospital. PATIENTS Five patients were evaluated: 4 with a history of OGIB (transfusion dependent in 2) and 1 patient with Peutz-Jeghers syndrome (PJS) under small-bowel surveillance. INTERVENTIONS CE was performed in all patients. Further evaluation via DBE, CTE, or MRE was performed. Definitive treatment was carried out by enteroscopic polypectomy (1 patient), surgical resection (2 patients), and transjugular intrahepatic portosystemic shunt procedure and embolization (1 patient). MAIN OUTCOME MEASUREMENTS Detection of significant small-bowel pathology by using DBE, CT, or MRE after a negative capsule study. RESULTS Significant small-bowel pathology was missed at CE but was detected by alternative modalities in 5 patients. In 4 patients, the lesions were in the proximal small bowel (adenocarcinoma, malignant melanoma, varices, and stromal tumor). The fifth patient had a large PJS polyp in the proximal ileum. LIMITATIONS Retrospective case series with small numbers. CONCLUSIONS Gross pathology may be missed at CE, especially in the proximal small bowel, and a negative CE study does not exclude significant disease. Alternative imaging modalities, such as DBE, CTE, or MRE, should be considered when clinical suspicion persists.

A Prospective Study of MR Enterography Versus Capsule Endoscopy for the Surveillance of Adult Patients With Peutz-Jeghers Syndrome

OBJECTIVE The objective of our study was to assess the utility of MR enterography compared with capsule endoscopy for the detection of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS). SUBJECTS AND METHODS Adult patients with PJS scheduled for surveillance capsule endoscopy were prospectively recruited and underwent MR enterography and capsule endoscopy. Polyps > 10 mm were regarded as clinically relevant. When appropriate, large polyps (> 15 mm) were removed at enteroscopy, enabling correlation with MR enterography and capsule endoscopy findings. Interobserver agreement for MR enterography and capsule endoscopy was calculated. Patient comfort, convenience, and test preference were assessed. RESULTS Nineteen patients (median age, 39.6 years) underwent both procedures. There was no significant difference between techniques for the detection of polyps > 10 mm (18 vs 23 polyps at capsule endoscopy and MR enterography, respectively; p = 0.35) or in the number of patients in whom > 10 mm polyps were detected (eight vs 11 patients at capsule endoscopy and MR enterography, respectively; p = 0.38). However, in three patients, large polyps (> 15 mm) detected on MR enterography were not detected on capsule endoscopy; large polyps were seen in six patients at capsule endoscopy and in nine patients at MR enterography (p = 0.25). Interobserver agreement was high for MR enterography but was only fair for capsule endoscopy (kappa = 0.81 and 0.27, respectively). Size assessments of large polyps (> 15 mm) appeared more reproducible with MR enterography than with capsule endoscopy. Patients rated capsule endoscopy as more comfortable than MR enterography. There was no significant difference between the techniques with regard to patient convenience or preference. CONCLUSION MR enterography is a promising alternative to capsule endoscopy for small-bowel surveillance in adults with PJS. Although our results suggest that capsule endoscopy is more comfortable for the patient, MR enterography may be less prone to missing large polyps and may be more reliable in their size assessment.

Safety, Reliability and Limitations of the Given Patency Capsule in Patients at Risk of Capsule Retention: A 3-Year Technical Review

Introduction The patency capsule may prevent capsule retention in high-risk patients. However data on its use in routine clinical practice is limited. Methods Patients referred to our institution between Feb-04 and Jan-07 were reviewed. The following data was collected: presenting symptoms; medical/surgical history; medication; radiology; patency/video capsule result; subsequent investigations; clinical outcomes. Results 373 patients were referred. In 315 (84%) ‘low-risk’ patients (no patency capsule): delayed transit occurred in three, with no cases of capsule retention. In 58 (16%) ‘high risk’ patients (patency capsule): asymptomatic retention occurred in eight, all with pathology despite normal prior barium studies in six; in four cases patency location was incorrectly assessed radiologically, leading to video capsule retention and surgery in one. Discussion Most patients can safely undergo capsule endoscopy without a patency capsule. The patency capsule appears safe and is indicative of pathology when retained. Assessment of patency capsule location post ingestion can be difficult, and if barium radiology is equivocal a limited abdominal computed tomography (CT) scan is suggested.

Feasibility of video capsule endoscopy in the management of children with Peutz-Jeghers syndrome: a blinded comparison with barium enterography for the detection of small bowel polyps.

Objectives: Peutz-Jeghers syndrome (PJS) in children may present with anaemia, intussusception, or obstruction from an early age and surgery is common. Prophylactic polypectomy may reduce subsequent complications. Traditional barium enterography (BE) has poor sensitivity and requires significant radiation. We compared the performance of capsule endoscopy (CE) with BE in children with PJS. Materials and Methods: Children with PJS (ages 6.0–16.5 years) were prospectively recruited and underwent BE followed by CE, each reported by expert reviewers blinded to the alternate modality. Number of “significant” (>10 mm) and total number of polyps were recorded. Child preference was assessed using a visual analogue questionnaire. Definitive findings were assessed at laparotomy or enteroscopy, when performed. Results: There was no significant difference for >10 mm polyp detection. Six polyps were found in 3 children by both modalities: 3 polyps in 2 children at CE, 3 polyps in 1 child at BE (P = 0.50). Re-review of 1 CE identified 3 polyps that were missed in 1 child at initial reading. Significantly more <10 mm polyps were identified by CE than BE: 61 vs 6 (P = 0.02). CE was significantly more comfortable than BE (median score CE 76 [interquartile range 69–87] vs BE 37 [interquartile range 31–68], P = 0.03) and was the preferred investigation in 90% (P = 0.02). Conclusions: CE is a feasible, safe, and sensitive test for small bowel polyp surveillance in children with PJS. It is significantly more comfortable than BE and is the preferred test of most children for future surveillance. There is a learning curve for reporting CE studies in PJS and appropriate training is essential.

Should We Be Using Bowel Preparation and Prokinetic Agents for Small Bowel Capsule Endoscopy? A Prospective Randomized Controlled Trial

randomized to PEG, OSPS, or dual (OSPSþPEG) preparations. Subjects with GFR %60 ml/min were not randomized to OSPS or dual preparation. Blood and early morning spot urine were collected 1 wk prior to (v1), on day of (v2) and 1 wk after C (v3) for serum creatinine (Cr, mg/dL), estimated glomerular filtration rate (eGFR, ml/min), phosphorous (P, mg/dL), calcium (Ca, mg/dL) with urinary P, creatinine, and N-acetyl-Dglucosaminidase (NAG, IU/mg of creatinine), a lysosomal enzyme released in urine after tubular injury. Effect on renal function was assessed by absolute change in Cr, percent change in Cr and eGFR at v2 and v3 compared to v1. Results: A total of 165 subjects (AB Z 139; mean age: 58 1 y and SCI Z 26; mean age: 60 2y; p Z 0.3) were analyzed. Bowel preparation was achieved with PEG in 55 (AB Z 47; SCI Z 8), OSPS in 55 (AB Z 47; SCI Z 8), and dual in 56 (AB Z 46; SCI Z 10) subjects. In AB subjects, Cr at v2 increased with OSPS (0.9 0.2 to 0.94 0.3) and dual (0.9 0.2 to 0.91 0.2) preparation, but decreased in SCI subjects (0.7 0.2 to 0.6 0.2) and returned to baseline by v3. Absolute change in Cr at v2 was higher in AB subjects compared to SCI with OSPS (0.01 0.02 vs -0.09 0.03, p ! 0.04) and dual (0.04 0.03 vs. -0.1 0.05, p ! 0.07). Percent change in Cr was higher with OSPS (2.1 2.2 vs -12 4.6, p ! 0.01) and dual (4 3.4 vs. -12 6.3, p ! 0.03) but not with PEG (2.1 2.2 vs. -12 4.5, p O 0.1). Changes in eGFR paralleled Cr changes. In AB subjects, OSPS increased serum P (3.2 0.5 to 5.7 1.7, p ! 0.0001), urinary P (67 6 to 405 40, p ! 0.0001), urinary NAG (0.4 0.05 to 0.6 0.1, p ! 0.02) and decreased serum Ca (9.2 0.4 to 8.8 8.8 0.4m p ! 0.0005) at v2. Similar trends were seen with dual but not with PEG. With OSPS in SCI subjects, changes in serum P (increase) and Ca (decrease) were similar to AB subjects without significant change in urinary P or NAG. Conclusion: Ingestion of OSPS alone or in combination with PEG resulted in elevation of serum P with decrease in Ca in AB and SCI subjects. Transient, but clinically insignificant, deterioration of renal function occurs in AB subjects. SCI subjects are less predisposed to this toxicity of OSPS and use of OSPS appears to be safe for routine C in them.