Edward J. Despott

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.

Effective dilation of small-bowel strictures by double-balloon enteroscopy in patients with symptomatic Crohn's disease (with video)

BACKGROUND Crohns disease (CD)-related small-bowel strictures remain a major cause of morbidity, frequently requiring surgery. OBJECTIVE Assessment of the feasibility and effectiveness of CD small-bowel stricture dilation by DBE. DESIGN Prospective case series. SETTINGS Single, tertiary referral center. METHODS Outcome data on cases of DBE-assisted CD small-bowel stricture dilation were prospectively collected from 2005. Dilation was performed by using controlled radial expansion balloon dilators. A 10-cm visual analogue scale (VAS) was used to assess obstructive symptoms and dietary restriction before DBE stricture dilation and at follow-up. RESULTS A total of 13 DBEs were performed in 11 consecutive patients (mean +/- SD age 46.4 +/- 7.8 years). Eighteen small-bowel stricture dilations were performed in 9 of 11 patients. The mean dilation diameter was 15.4 mm (range 12-20 mm). In 2 cases, stricture dilation was not performed because adhesions made reaching the strictures impossible. One case was complicated by a delayed perforation. In the other 8 patients, stricture dilation was successful; VAS scores improved dramatically and none of the patients has required surgery (mean follow-up 20.5 months; range 2-41 months). During follow-up, 2 patients required repeated dilation (at 6.5 and 13 months, respectively) because of symptom recurrence. Clinical improvements in before and after VAS scores were significant (mean 8.8 vs 1.8, respectively; P < .001). LIMITATIONS Small case series; single tertiary referral center. CONCLUSION DBE-assisted small-bowel stricture dilation for selected patients with CD is potentially of significant benefit and should be considered as a useful and effective alternative to surgery. Larger studies are required to confirm this benefit.

Sedation in digestive endoscopy: the Athens international position statements

Aliment Pharmacol Ther 2010; 32: 425–442

Enteral Access by Double-Balloon Enteroscopy: An Alternative Method of Direct Percutaneous Endoscopic Jejunostomy Placement

BackgroundAlthough direct percutaneous endoscopic jejunal feeding tube placement is an increasingly accepted method of providing small-bowel access for long-term enteral nutrition, it is reliant on push enteroscopy and remains a technically challenging procedure with significant failure rates. Double-balloon enteroscopy, with its ability to provide controlled small-bowel intubation may facilitate direct percutaneous endoscopic jejunal tube placement.Aims and MethodsWe report a prospective series of ten consecutive cases of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunal placement, accompanied by a step-by-step illustrated overview of the technique.ResultsDirect percutaneous endoscopic jejunal tube placement by double-balloon enteroscopy was successful in nine of the ten attempted cases. In the first case, direct percutaneous endoscopic jejunal placement was abandoned due to inadequate transillumination; there were no procedure-related complications in any of our patients.ConclusionsThis first reported prospective case series of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunal placement shows a promisingly high success rate; larger comparative studies are required to clearly establish any advantages over the originally described push enteroscopy method.

Anti-tumour necrosis factor agent and liver injury: Literature review, recommendations for management

Abnormalities in liver function tests, including transient and self-limiting hypertransaminasemia, cholestatic disease and hepatitis, can develop during treatment with anti-tumour-necrosis-factor (TNF) therapy. The optimal management of liver injury related to anti-TNF therapy is still a matter of debate. Although some authors recommend discontinuing treatment in case of both a rise of alanine aminotransferase more than 5 times the upper limit of normal, or the occurrence of jaundice, there are no standard guidelines for the management of anti-TNF-related liver injury. Bibliographical searches were performed in PubMed, using the following key words: inflammatory bowel disease (IBD); TNF inhibitors; hypertransaminasemia; drug-related liver injury; infliximab. According to published data, elevation of transaminases in patients with IBD treated with anti-TNF is a common finding, but resolution appears to be the usual outcome. Anti-TNF agents seem to be safe with a low risk of causing severe drug-related liver injury. According to our centre experience, we found that hypertransaminasemia was a common, mainly self-limiting finding in our IBD cohort and was not correlated to infliximab treatment on both univariate and multivariate analyses. An algorithm for the management of liver impairment occurring during anti-TNF treatment is also proposed and this highlights the need of a multidisciplinary approach and suggests liver biopsy as a key-point in the management decision in case of severe rise of transaminases. However, hepatic injury is generally self-limiting and drug withdrawal seems to be an exception.

Tracheal Aspiration of Capsule Endoscopes: Detection, Management, and Susceptibility

Dear Editors, We read with interest the article by Lucendo et al. [1] and subsequent correspondence from Koulaouzidis et al. [2] and wish to include a further three cases (two from the United Kingdom and one from Australia) of tracheal aspiration of capsule endoscopes, bringing the total number of worldwide cases reported to date to 18. Our first case involved a 65-year-old man with suspected obscure gastrointestinal bleeding, history of ethanol induced cirrhosis, chronic pancreatitis and chronic obstructive pulmonary disease (COPD). Other than demonstrating small non-bleeding gastric varices, several upper GI endoscopies (EGD) and colonoscopies were unhelpful. At the time of capsule endoscopy (CE), although the patient appeared frail and undernourished there was no history of dysphagia. Following capsule ingestion (in the upright position), the patient remained asymptomatic but the ‘‘real-time viewer’’ (RTV) showed immediate aspiration of the capsule into the bronchial tree. A chest X-ray identified the capsule to the right of the midline below the bifurcation of the trachea (Fig. 1). Rigid bronchoscopy under general anesthesia (GA) was urgently performed with the capsule found deep in the right main bronchus (Fig. 2). Initial retrieval efforts using a Roth Net (US Endoscopy, USA) were unsuccessful—full deployment of the net was impossible within the narrow bronchial confines; further attempts at extraction using a Cryo-probe (ERBE Elektromedizin GmbH, Germany) and balloon traction with a Fogarty endovascular catheter also failed. Successful retrieval was ultimately achieved with large ‘‘crocodile’’ grasping forceps. A second capsule was then placed without incident into the duodenum using an AdvanCE device (Given imaging, Israel) while the patient remained under GA. The second case involved a 73-year-old man with COPD and persistent iron deficiency anemia (IDA). EGD, colonoscopy and abdominal CT scan were unremarkable. Capsule ingestion resulted in brief coughing and RTV images confirmed aspiration (Fig. 3). Retrieval of the capsule from the left main bronchus at bronchoscopy under conscious sedation using a snare was unsuccessful. The patient was then asked to cough, which led to disimpaction and successful capsule capture using a Roth Net . Another capsule was then deployed into the duodenum using an AdvanCE device. Our final case involved an 81-year-old man with recurrent IDA and negative EGD and colonoscopy. He described a fleeting choking sensation during ingestion of the capsule but otherwise remained asymptomatic. RTV images confirmed capsule aspiration and rigid bronchoscopy was performed with removal of the capsule from the right main bronchus using large crocodile grasping forceps. We agree with our colleagues’ view that CE is associated with a small but definite risk of capsule aspiration [1] in a subset of patients who undergo CE and that this deserves greater clinical recognition. E. J. Despott A. O’Rourke C. Fraser (&) Wolfson Unit for Endoscopy, St Mark’s Hospital and Academic Institute, Imperial College London, Northwick Park Campus, London, UK e-mail: chris.fraser@imperial.ac.uk

Provision of service and training for small bowel endoscopy in the UK

Objective To determine the location and use of small bowel endoscopy services in the UK and to analyse training uptake to assess future demand and shape discussions about training and service delivery. Design Surveys of British Society of Gastroenterology (BSG) members by web-based and personal contact were conducted to ascertain capsule endoscopy practice and numbers of procedures performed. This was compared with expected numbers of procedures calculated using BSG guidelines, hospital episode statistics and published data of capsule endoscopy in routine practice. Analysis of data from two national training courses provided information about training. Results 45% of UK gastroenterology services offered in-house capsule endoscopy. 91.3% of survey responders referred patients for capsule endoscopy; 67.7% felt that local availability would increase referrals. Suspected small bowel bleeding and Crohns disease were considered appropriate indications by the majority. Demand is increasing in spite of restricted use in 21.6% of centres. Only two regions performed more than the minimum estimate of need of 45 procedures per 250 000 population. Eight centres perform regular device-assisted enteroscopy; 14 services are in development. 74% of trainees were interested in training and of those training in image interpretation, 67% are doctors and 28% are nurses. Conclusions Capsule endoscopy is used by the majority of UK gastroenterologists but appears to be underused. Current demand for device-assisted enteroscopy seems likely to be matched if new services become established. Future demand is likely to increase, however, suggesting the need to formalise training and accreditation for both doctors and nurses.

Small bowel endoscopy in inflammatory bowel disease

The last decade has witnessed a revolution in small bowel (SB) endoscopy technologies. Endoscopists are no longer confined to the use of push enteroscopy or the significantly more invasive intra-operative enteroscopy: SB capsule endoscopy (SBCE) and device assisted enteroscopy (DAE) have rapidly enabled endoscopic visualisation of the entire SB without the need for surgery. DAE goes a step further by allowing tissue sampling and the application of endotherapy. These developments have also been parallelled by rapid advances in dedicated radiological SB imaging technologies. Although it is clear that SBCE and DAE may have a significant role in the diagnosis and management of IBD patients, their respective place in relation to other technologies within the clinical paradigm of IBD is as yet unclear. This review outlines the current evidence base relating to these endoscopic technologies and their impact in the diagnosis and management of IBD and highlights current international recommendations.

Factors associated with reduced insertion depth at double balloon enteroscopy: A retrospective, multivariate analysis

BACKGROUND Deep small bowel insertion during double balloon enteroscopy can be difficult to achieve. AIMS To determine the factors influencing depth of insertion during double balloon enteroscopy. METHODS History of abdomino-pelvic surgery, route of insertion, type of enteroscope, age, sedation or general anaesthesia used and gender were considered as potential influencing factors; procedures were categorised accordingly and maximal depth of insertion calculated. RESULTS At multivariate analysis, maximal depth of insertion was significantly associated with history of abdominal-pelvic surgery (P<0.001), rectal approach (P=0.011), gender (P=0.02) and use of the therapeutic enteroscope (P=0.047). Mean maximal depth of insertion was 266±12cm, 255±9cm (P=0.50), 197±10cm (P<0.0001), 160±12cm (P<0.01) and 103±33cm (P<0.15) when 0, 1, 2, 3 and 4 influencing factors were present, respectively. CONCLUSION Maximal depth of insertion was significantly influenced by history of abdomino-pelvic surgery, insertion route, gender and type of enteroscope used.

A prospective comparison of performance during back-to-back, anterograde manual spiral enteroscopy and double-balloon enteroscopy

BACKGROUND Spiral enteroscopy is a recently introduced technology alternative to balloon-assisted enteroscopy for examination of the small bowel. AIM To compare small bowel insertion depths and procedure duration by spiral enteroscopy and double-balloon enteroscopy performed in the same cohort of patients, in immediate succession, using the same method of insertion depth estimation. METHODS A prospective, back-to-back comparative study was performed in 15 patients. Spiral enteroscopy procedures were performed first and a tattoo was placed to mark the most distal point. RESULTS Double-balloon enteroscopy passed the tattoo placed at spiral enteroscopy in 14/15 cases (93%). Median insertion depths for double-balloon enteroscopy and spiral enteroscopy were 265cm and 175cm, respectively (P=0.004). Median time to achieve maximal depth of insertion was significantly shorter for spiral enteroscopy compared with double-balloon enteroscopy (24min vs. 45min, respectively; P=0.0005). However, in 14 patients no differences were found in median time to reach the same insertion depth (P=0.28). CONCLUSION Double-balloon enteroscopy achieved significantly greater small bowel insertion depth than spiral enteroscopy. Although overall double-balloon enteroscopy procedure duration was longer, the time taken to reach the same small bowel insertion depth by both spiral enteroscopy and double-balloon enteroscopy was similar.