Clotilde Lérias

Capsule endoscopy in inflammatory bowel disease type unclassified and indeterminate colitis serologically negative

Background: The value of capsule endoscopy in the setting of inflammatory bowel disease type unclassified (IBDU) and indeterminate colitis (IC) remains obscure. The aim was to evaluate the clinical impact of capsule endoscopy on IBDU/IC patients with negative serology. Methods: Eighteen patients with long‐standing IBDU (n = 14) and IC (n = 4) were enrolled to undergo a capsule endoscopy and then followed prospectively. Lesions considered diagnostic of Crohns disease (CD) were 4 or more erosions/ulcers and/or a stricture. The median follow‐up time after capsule endoscopy was 32 ± 11 months (23–54 months). Results: Total enteroscopy was possible in all patients. In 2 patients the examination was normal (Group 1). In 9 patients subtle findings were observed (Group 2): focal villi denudation (n = 1) and fewer than 4 erosions/ulcers (n = 8). In 7 patients, 4 or more erosions/ulcers were detected (Group 3), leading to a diagnosis of CD. However, their treatment was not reassessed on the basis of the capsule findings. Until now, a definitive diagnosis has been achieved in 2 additional patients: 1 from Group 1 (ulcerative colitis) and another patient from Group 2 (CD), who began infliximab infusions. Nine patients remained indeterminate at follow‐up. Conclusions: Although capsule endoscopy enabled the diagnosis of CD in 7 patients, in none of them was the clinical management changed. Moreover, a change in therapy due to a diagnosis of CD was made for only 1 patient, who presented nonspecific findings. Our results suggest that capsule findings are not helpful in the work‐up of these patients. Inflamm Bowel Dis 2010

Small-Bowel Capsule Endoscopy in Patients with Suspected Crohn's Disease—Diagnostic Value and Complications

Background. The aim of this work was to assess the value of capsule enteroscopy in the diagnosis of patients with suspected Crohns Disease (CD). Methods. This was a retrospective study in a single tertiary care centre involving patients undergoing capsule enteroscopy for suspected CD. Patients taking nonsteroidal anti inflammatory drugs during the thirty preceding days or with a follow-up period of less than six months were excluded. Results. Seventy eight patients were included. The endoscopic findings included mucosal breaks in 50%, ulcerated stenosis in 5%, and villous atrophy in 4%. The diagnosis of CD was established in 31 patients. The sensitivity, specificity, positive and negative predictive value of the endoscopic findings were 93%, 80%, 77%, and 94%, respectively. Capsule retention occurred in four patients (5%). The presence of ulcerated stenosis was significantly more frequent in patients with positive inflammatory markers. The diagnostic yield of capsule enteroscopy in patients with negative ileoscopy was 56%, with a diagnostic acuity of 93%. Conclusions. Small bowel capsule endoscopy is a safe and valid technique for assessing patients with suspected CD. Capsule retention is more frequent in patients with positive inflammatory markers. Patients with negative ileoscopy and suspected CD should be submitted to capsule enteroscopy.

URGENT CAPSULE ENDOSCOPY IS USEFUL IN SEVERE OBSCURE-OVERT GASTROINTESTINAL BLEEDING

Aim:  With capsule endoscopy (CE) it is possible to examine the entire small bowel. The present study assessed the diagnostic yield of CE in severe obscure‐overt gastrointestinal bleeding (OOGIB).

Capsule endoscopy assisted by traditional upper endoscopy

BACKGROUND AND AIMS Capsule endoscopy (CE) can be prevented by difficulties in swallowing the device and/or its gastric retention. In such cases, endoscopic delivery of the capsule to duodenum is very useful. We describe the indications and outcomes of cases in which traditional endoscopic techniques allowed placement of the capsule in duodenum. PATIENTS AND METHODS This is a retrospective, descriptive case series. All patients in the above conditions were identified and indications for CE, endoscopic-placement technique, complications and completeness of small bowel imaging were registered. RESULTS Endoscopic-assisted delivery of the capsule was necessary in 13 patients (2.1% of all CE; 7 males; mean age--47.9 +/- 24.9 years, range 13 to 79 years). Indications for endoscopic delivery included: inability to swallow the capsule (7), gastric retention in previous exams (3), abnormal upper gastrointestinal anatomy (3). In eight patients, the capsule was introduced in GI tract with: foreign body retrieval net alone (3), retrieval net and a translucent cap (2), prototype delivery device (2) or a polypectomy snare (1). Five patients ingested the capsule that was then placed in duodenum with a polypectomy snare (3) or a retrieval net (2). No major complications occurred. Complete small bowel examination was possible in 10 patients (77%). CONCLUSIONS Endoscopic placement of capsule endoscope in the duodenum is rarely needed. However it may be safely performed by different techniques avoiding some limitations of CE. The best methods for endoscopic delivery of the capsule in the duodenum seem to be retrieval net with a translucent cap when the patient is unable to swallow the device or a retrieval net only to capture the capsule in the stomach when the patients swallows it easily.

Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding

BACKGROUND in 21st century, endoscopic study of the small intestine has undergone a revolution with capsule endoscopy and balloon-assisted enteroscopy. The difficulties and morbidity associated with intraoperative enteroscopy, the gold-standard in the 20th century, made this technique to be relegated to a second level. AIMS evaluate the actual role and assess the diagnostic and therapeutic value of intraoperative enteroscopy in patients with obscure gastrointestinal bleeding. PATIENTS AND METHODS we conducted a retrospective study of 19 patients (11 males; mean age: 66.5 ± 15.3 years) submitted to 21 IOE procedures for obscure GI bleeding. Capsule endoscopy and double balloon enteroscopy had been performed in 10 and 5 patients, respectively. RESULTS with intraoperative enteroscopy a small bowel bleeding lesion was identified in 79% of patients and a gastrointestinal bleeding lesion in 94%. Small bowel findings included: angiodysplasia (n = 6), ulcers (n = 4), small bowel Dieulafoy´s lesion (n = 2), bleeding from anastomotic vessels (n = 1), multiple cavernous hemangiomas (n = 1) and bleeding ectopic jejunal varices (n = 1). Agreement between capsule endoscopy and intraoperative enteroscopy was 70%. Endoscopic and/or surgical treatment was used in 77.8% of the patients with a positive finding on intraoperative enteroscopy, with a rebleeding rate of 21.4% in a mean 21-month follow-up period. Procedure-related mortality and postoperative complications have been 5 and 21%, respectively. CONCLUSIONS intraoperative enteroscopy remains a valuable tool in selected patients with obscure GI bleeding, achieving a high diagnostic yield and allowing an endoscopic and/or surgical treatment in most of them. However, as an invasive procedure with relevant mortality and morbidity, a precise indication for its use is indispensable.

SMALL BOWEL PSEUDOMELANOSIS AND ORAL IRON THERAPY

Small bowel pseudomelanosis is a rarely reported clinical entity characterized by brown pigmentation of small bowel mucosa. The authors describe two cases, both with iron deficiency anemia, one of an 81‐year‐old female patient submitted for capsule endoscopy that revealed a brown pigmentation of all small bowel mucosa and another of an 81‐year‐old male whose retrograde double‐balloon enteroscopy revealed a diffuse brown pattern of small bowel mucosa. Ileal biopsies confirmed intense iron deposition in the macrophages of the lamina propria. Both patients were on oral iron therapy and the second one had a previous double‐balloon enteroscopy, 2 years earlier, which revealed only ileal angiodysplasias. These two cases demonstrate the importance of two new endoscopic methods for diagnosis of small bowel pseudomelanosis, the rarity of such an entity and its close relation with oral iron therapy.

Association between the location of colon polyps at baseline and surveillance colonoscopy: a retrospective study

INTRODUCTION Several factors are used to stratify the probability of polyp recurrence. However, there are no studies correlating the location of the initial polyps and the recurrent ones. The aim of this study was to verify whether the polyp location at the surveillance colonoscopy was correlated with the location of the previously excised polyps at the baseline colonoscopy. METHODS A retrospective study of patients submitted to colonoscopy with presence and excision of all polyps, followed by a surveillance colonoscopy. Polyp location was divided into proximal/distal to splenic flexure and rectum. Characteristics and recurrent rates at the same colon location were also evaluated. RESULTS Out of the 346 patients who underwent repeated colonoscopy, 268 (77.4%) had at least 1 polyp detected. For all the segments there was an increased risk of recurrent polyps in the same location and it was about four times higher in proximal (OR 3.5; CI 2.1-6.0) and distal colon segments (OR 3.8; CI 2.1-6.8), followed by three times higher in the rectum (OR 2.6; CI 1.5-4.6). No difference was found between the rates of recurrence at the same segment, taking into consideration the polyp morphology, size, polypectomy technique employed and histological classification. CONCLUSION There seems to be a significant association between polyp location at baseline and surveillance colonoscopy.

7049 Endoscopic placement of esophageal expandable metal stents without fluoroscopic guidance.

The insertion of expandable metal stents (EMS) is a fundamental palliative treatment for esophageal malignant neoplasia. Endoscopic placement of stents is usually performed under fluoroscopic guidance. Aims: Evaluation of feasability, efficacy and safety of the endoscopic insertion of EMS in esophageal malignant neoplasia without fluoroscopic guidance. Patients and Methods: Retrospective study of 60 patients (pts) with nonresectable esophageal cancer in whom 72 EMS were placed. The EMS used were distal release Ultraflex™ (Microvasive®, Boston Scientific Corporation), 7-15 cm long and 18 mm in diameter (22 covered stents). 91% of the patients were previously submitted to dilation and/or Nd:YAG laser. The procedures were done under sedation with midazolam and EMS were placed under endoscopic control with no fluoroscopic guidance. Severity of dysphagia was graded in a 0 to 4 score according to the consistency of food causing symptoms: 0 no dysphagia; 1 solid food; 2 semi-solid food; 3 liquid food; 4 total dysphagia. Results: 49 men and 11 women. Mean age 65±11 years. The indications for EMS insertion were dysphagia (78%) and esophagorespiratory fistulas (22%). Mean stricture length: 7.0±1.9 cm.The neoplasia were located in the upper esophagus in 23%, in the middle in 47% and in the lower in 30%. A significant improvement in dysphagia after stent placement was observed (mean pre-treatment score: 3.1±0.7; mean score after stenting: 1.5±0.5 - p