Blair S. Lewis

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.

Colonoscopy : a prospective report of complications

Patients (N = 2,097) undergoing ambulatory office colonoscopy were followed to determine the incidence of endoscopic complications. In this group, 1,320 patients had diagnostic colonoscopy with or without biopsy; 777 patients had 2,019 polyps removed. Three of 2,097 patients (0.1%) had transient hypotension requiring i.v. fluid resuscitation and oxygen administration. All patients went home without sequelae. Acute postpolypectomy bleeding occurred in 11 of 777 patients (1%) requiring acute management; bleeding was controlled during colonoscopy in all. Postpolypectomy syndrome occurred in 9 of 777 patients (1%). All patients were treated medically. Late postpolypectomy bleeding occurred in 15 of 777 patients (2%). Perforation occurred in two of 777 patients (0.3%), at 1 and 9 days postpolypectomy. Both patients underwent surgery with uneventful recoveries. We conclude that office colonoscopy including polypectomy is safe. The overall complication rate for therapeutic ambulatory colonoscopy was 5%, with major events requiring hospitalization in 2% of patients.

The Risk of Retention of the Capsule Endoscope in Patients with Known or Suspected Crohn's Disease

OBJECTIVES:Capsule endoscopy (CE) allows visualization of the mucosa of the entire small bowel and is therefore a potentially important tool in the evaluation of patients with known or suspected Crohns disease (CD). However, small bowel strictures, which are not uncommon in Crohns, are considered to be a contraindication to CE for fear of capsule retention. Our goal was to determine the risk of capsule retention in patients with suspected or known CD.METHODS:We retrospectively reviewed the records of 983 CE cases performed at three private gastroenterology practices between December 2000 and December 2003, and selected those with suspected or proven Crohns.RESULTS:A total of 102 cases were identified in which CE was used in patients with suspected (N = 64) or known (N = 38) CD. Only one of 64 patients (1.6%) with suspected CD had a retained capsule. However, in five of 38 (13%) patients with known Crohns, the capsule was retained proximal to a stricture. Of the five cases of retained capsules, three strictures were previously unknown. In four cases, the obstructing lesions were resected without complications, leading to complete resolution of the patients underlying symptoms. One patient chose not to undergo surgery and has remained without an episode of small bowel obstruction for over 38 months.CONCLUSIONS:Capsule retention occurred in 13% (95% CI 5.6%–28%) of patients with known CD, but only in 1.6% (95% CI 0.2%–10%) with suspected Crohns. A retained capsule may indicate unsuspected strictures in Crohns that may require an unexpected, but therapeutic, surgical intervention. Patients and physicians should be aware of these potential risks when using CE in CD.

A prospective study of the diagnostic accuracy of PillCam ESO esophageal capsule endoscopy versus conventional upper endoscopy in patients with chronic gastroesophageal reflux diseases

Introduction: Endoscopy is commonly performed to evaluate for suspected or established esophageal diseases including gastroesophageal reflux disease (GERD) and its complications. The newly developed PillCam ESO Esophageal Capsule offers an alternative approach to visualize the esophagus and to evaluate patients with suspected esophageal disease. Aim: Compare the accuracy (specificity, sensitivity, positive predictive value [PPV], and negative predictive value [NPV]) of esophageal capsule endoscopy (ECE) compared with esophagogastroduodenoscopy (EGD) in evaluating patients with GERD. Methods: A multicenter pivotal trial was conducted at seven sites. The PillCam ESO esophageal capsule is similar to the standard capsule endoscope used for the small bowel but acquires video images from both ends of the device at 2 frames/second/end. A total of 106 patients (93 GERD; 13 Barrett) underwent ECE followed by EGD. ECE videos were evaluated by an investigator blinded to EGD findings. A blinded adjudication committee reviewed all discrepant findings between ECE and EGD. Results: Sixty-six of 106 patients had positive esophageal findings, ECE identified esophageal abnormalities in 61 (sensitivity, 92%; specificity, 95%). The per-protocol sensitivity, specificity, PPV, and NPV of ECE for Barrett esophagus were 97%, 99%, 97%, and 99%, respectively, and for esophagitis 89%, 99%, 97%, and 94%, respectively. ECE was preferred over EGD by all patients. There were no adverse events related to ECE. Conclusions: ECE is a convenient and sensitive method for visualization of esophageal mucosal pathology and may provide an effective method to evaluate patients for esophageal disease.

Small bowel tumours: yield of enteroscopy.

A total of 258 patients with obscure gastrointestinal bleeding were referred for small bowel enteroscopy, a procedure which allows endoscopic evaluation of most of the small intestine. A small bowel tumour was found in 5% of patients. In 50% of patients no diagnosis could be made, but when the cause of obscure bleeding was discovered small bowel tumours were the single most common lesion in patients younger than 50 years. Small bowel tumours causing gastrointestinal bleeding may remain undetected despite extensive diagnostic evaluation. We conclude that small bowel tumours are the most common cause of obscure gastrointestinal bleeding in patients less than 50 years of age. Small bowel enteroscopy is diagnostic of small bowel tumours even when all previous diagnostic studies, including enteroclysis and angiography, are negative.

Capsule endoscopy retention: is it a complication?

Background Capsule endoscopy has been found superior to barium x-rays and push enteroscopy in the investigation of obscure gastrointestinal bleeding and in the evaluation of suspected Crohns disease. Currently, small bowel obstruction and strictures are considered by many physicians to be a contraindication to capsule endoscopy for fear of capsule retention or impaction. The goal of this study was to reassess this conventional wisdom that capsule endoscopy is contraindicated in small bowel obstruction and to determine the safety and efficacy of capsule endoscopy in the evaluation of patients with suspected stricture or small bowel obstruction. Study A retrospective chart review was performed using a database of 568 capsule endoscopy cases performed between August 2001 and November 2003. Cases of suspected small bowel obstruction were selected and reviewed. Results Nineteen cases were identified in which capsule endoscopy was used in the setting of suspected small bowel obstruction. The diagnosis of suspected small bowel obstruction was based on symptoms alone in 8 cases and on symptoms plus abnormal radiographs in the remaining 11 cases. Capsule endoscopy made a definitive diagnosis in 5 of the 19 cases (26%): 2 Crohns strictures, 1 radiation induced stricture, 1 nonsteroidal anti-inflammatory drug induced stricture, and 1 MALT lymphoma. The capsule was retained proximal to a stricture in 4 cases, in which the obstructing lesions were electively resected without complications. There was no case in which administration of the capsule led to an acute small bowel obstruction. Conclusions Capsule endoscopy can be safely used to help identify the etiology and site of a small bowel obstruction. Retention of the capsule may indicate the presence of a lesion requiring surgery, but small bowel obstruction or strictures are not in themselves contraindications to the procedure. It is understood, however, that retention may lead to surgery in a patient who otherwise may have been treated medically without surgery for the same illness (eg, Crohns disease and nonsteroidal anti-inflammatory drug enteropathy).

Push enteroscopic cauterization: long-term follow-up of 83 patients with bleeding small intestinal angiodysplasia

BACKGROUND This study assessed the long-term effectiveness of push enteroscopic cauterization of bleeding intestinal angiodysplasia. METHODS We retrospectively reviewed the clinical course of patients who underwent push and sonde enteroscopy for obscure gastrointestinal bleeding and were diagnosed with intestinal angiodysplasias. RESULTS One hundred twelve patients bleeding from small intestinal angiodysplasias were identified. After excluding those lost to follow-up (29), data were collected from 83 patients. Fifty-five patients (29 men; mean age, 73 years; mean units of packed red blood cells transfused, 21.4; average bleeding history, 22 months) were cauterized. Twenty-eight patients (12 men; mean age, 71; mean units of packed red blood cells transfused, 15.8; average bleeding history, 22 months) were not cauterized. The noncauterized group (follow-up, 26 +/- 14 months; mean +/- SD) continued to bleed, requiring 2.16 +/- 3.86 units of packed red blood cells transfused per month (units/month) before and 0.97 +/- 1.46 units/month after diagnosis (NS). The cauterized group (follow-up, 30 +/- 18 months) significantly improved, requiring 2.40 +/- 2.97 units/month before treatment and 0.32 +/- 0.91 units/month after cauterization (p < 0.0001, paired t test). CONCLUSION Cauterization of endoscopically accessible small intestinal angiodysplasias may decrease rebleeding.

Economic and health outcomes of capsule endoscopy: Opportunities for improved management of the diagnostic process for obscure gastrointestinal bleeding

The estimated annual incidence of gastrointestinal bleeding in the United States is approximately 100 episodes per 100,000 persons, resulting in 300,000 hospitalizations annually. Diagnostic tools such as radiologic studies and endoscopic examination often fail to identify a source of bleeding, resulting in a cycle of repetitive testing over months or even years. Costs associated with the diagnostic process, and with interim treatment for anemia and other symptoms, can be significant. The diagnostic process also takes a toll on the patient, in terms of worry, pain, and discomfort. Capsule endoscopy, a technology that received FDA clearance in August, 2001, consists of a video capsule that is ingested by the patient, and that transmits images to a wireless data recorder worn on the belt. The recorded stream of approximately 50,000 images can be reviewed on a computer workstation by a physician to identify nature and location of potential sources of bleeding. This paper presents a framework for economic ana...

The technique of abdominal pressure in total colonoscopy

Total colonoscopy can be difficult. It is recognized that abdominal pressure can be helpful in the performance of colonoscopy by externally splinting the endoscope to prevent loop formation. Properly applied abdominal pressure can limit patient discomfort and shorten examination time. Various techniques for abdominal pressure were studied in 201 consecutive patients who had total colonoscopy to the cecum. Abdominal pressure or change of body position was used 619 times in 165 patients (82%), with an average of 3.75 pressure applications per colonoscopy, most lasting less than 30 sec. Pressure was most commonly used when the endoscope tip was at the splenic flexure. Non-specific pressure to a region of the abdomen where looping developed, endoscopically observed specific pressure near the tip, and position change were used in a stepwise manner. Non-specific pressure was more successful in the left (78%) than in the right (47%) colon (p less than 0.0005). As intubation progressed left to right, specific pressure became more useful. When abdominal pressure was not useful, a change in patient position from left lateral to supine was successful in advancing the endoscope tip in 68% of patients.

Enteroscopy: An Overview

Although the small intestine has long been considered the final frontier of endoscopy, a vast amount of progress has led to increased diagnostic and therapeutic capabilities. With the increasing prevalence of capsule endoscopy, the need for enteroscopy also continues to increase. The endoscopic options currently available include double and single balloon-assisted enteroscopy, spiral enteroscopy, and lastly, intraoperative enteroscopy. The majority of published literature has focused on double balloon enteroscopy, but further studies have to provide information on the safety and yield of the newer techniques. Although intraoperative enteroscopy may be practiced less frequently, it has a role in the management of lesions that may not be approachable by other endoscopic means and a role in the guidance of surgical management.