K Drew

Colonoscopic resection of lateral spreading tumours: a prospective analysis of endoscopic mucosal resection

Background: Lateral spreading tumours are superficial spreading neoplasms now increasingly diagnosed using chromoscopic colonoscopy. The clinicopathological features and safety of endoscopic mucosal resection for lateral spreading tumours (G-type “aggregate” and F-type “flat”) has yet to be clarified in Western cohorts. Methods: Eighty two patients underwent magnification chromoscopic colonoscopy using the Olympus CF240Z by a single endoscopist. All patients had received a previous colonoscopy where an endoscopic diagnosis of lateral spreading tumour was made. All lesions were examined initially using indigo carmine chromoscopy to delineate contour followed by crystal violet for magnification crypt pattern analysis. A 20 MHz “mini probe” ultrasound was used if T2 disease was suspected. Following endoscopic mucosal resection, patients were followed up at 3, 6, 12, and 24 months using total colonoscopy. Results: Eighty two lateral spreading tumours were diagnosed in 80 patients (32% (26/82) F-type and 68% (56/82) G-type). G-type lesions were larger than F-type (G-type mean 42 (SD 14) mm v F-type 24 (6.4) mm; p<0.01). F-type lesions were more common in the right colon (F-type 77% (20/26) compared with G-type 39% (22/56); p<0.01) and more often associated with invasive disease (stage T2) (66% (10/15) v 33% (5/15); p<0.001). Fifty eight lesions underwent endoscopic mucosal resection (G-type 64% (37/58)/F-type 36% (21/58)). Local recurrent disease was detected in 17% of patients (10/58), all within six months of the index resection. Piecemeal resection and G-type morphology were significantly associated with recurrent disease (p<0.1). Overall “cure” rates for lateral spreading tumours using endoscopic mucosal resection at two years of follow-up was 96% (56/58). Conclusions: Endoscopic mucosal resection for lateral spreading tumours, staged as T1, is a safe and effective treatment despite their large size. Endoscopic mucosal resection may be an alternative to surgery in selected patients.

Capsule endoscopy in adult celiac disease: a potential role in equivocal cases of celiac disease?

BACKGROUND There have been limited studies evaluating capsule endoscopy (CE) in equivocal celiac disease (CD). OBJECTIVE To determine the role CE may have in equivocal CD cases, compared with patients with biopsy-proven and serology-proven CD who have persisting symptoms. DESIGN Prospective cohort study. SETTING University hospital. PATIENTS A total of 62 patients with equivocal CD and 69 patients with nonresponsive CD. INTERVENTION CE. MAIN OUTCOME MEASUREMENTS Diagnostic yield of CE in equivocal cases and accuracy of mucosal abnormality detection in patients with nonresponsive CD. RESULTS Equivocal cases (n = 62) were divided into two subgroups: group A (antibody-negative villous atrophy, n = 32) and group B (Marsh 1-2 changes, n = 30). In group A, CE secured a diagnosis of CD or Crohns disease in 28% (9/32), significantly higher than the diagnostic yield in group B (7%; P = .044). In patients with CD with persisting symptoms, significant CE findings were identified in 12% (8/69), including 2 cases of enteropathy-associated lymphoma, 4 type 1 refractory disease cases, 1 polypoidal mass histologically confirmed to be a fibroepithelial polyp, and 1 case of ulcerative jejunitis. This outcome was significantly lower than the diagnostic yield of CE in antibody-negative villous atrophy (P = .048). LIMITATIONS Single center. CONCLUSION There have been no previous reports systematically evaluating equivocal CD by using CE. The diagnostic yield of CE in patients with antibody-negative villous atrophy is better than that of CE in patients with CD with persisting symptoms. We advocate the use of CE in equivocal cases, particularly in patients with antibody-negative villous atrophy.

Evaluating the role of small-bowel endoscopy in clinical practice: the largest single-centre experience.

Objective There are few centres that offer all forms of small-bowel endoscopic modalities [capsule endoscopy (CE), push enteroscopy (PE), double-balloon enteroscopy (DBE) or single-balloon enteroscopy and intraoperative enteroscopy (IOE)]. Previous investigators have suggested that DBE may be more cost-effective as the first-line investigation. We evaluated the relationship among four modalities of small-bowel endoscopy in terms of demand, diagnostic yield, patient management and tolerability. Methods Data were collected on patients who underwent PE and IOE since January 2002, CE since June 2002 and DBE since July 2006. These included age, sex, indication of referral, comorbidity, previous investigations and diagnosis obtained, including subsequent management change. Results Demand for CE and DBE increased every year. A total of 1431 CEs, 247 PEs, 102 DBEs and 17 IOEs were performed over 93 months. The diagnostic yield was 88% for IOE compared with 34.6% for CE, 34.5% for PE and 43% for DBE (P<0.001). Management was altered by CE in 25%, by PE in 19% and by DBE in 33% of patients. However, 44% of patients who underwent DBE found the procedure difficult to tolerate. In 2009, for every 17 CEs performed, one patient underwent DBE locally. Conclusion This is the first series to report the clinical experience of four modalities of small-bowel endoscopy from a single centre. The use of CE as first-line investigation, followed by PE/DBE or IOE, is potentially both less invasive and tolerable.

Elevated serum chromogranin A in irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD): A shared model for pathogenesis?

To the Editor: Sciola et al have demonstrated that plasma chromogranin A levels are elevated in patients with inflammatory bowel disease (IBD), suggesting neuroendocrine system activation in response to inflammation. We would like to share our observations in this area. We studied the prevalence of elevated serum chromogranin A levels in patients with IBD and diarrhea predominant irritable bowel syndrome (D-IBS who fulfilled Rome II criteria). This study measured CgA levels in 39 patients with IBD and 87 patients with D-IBS. We used the new competitive radioimmunoassay that uses antibodies against human CgA (EURO-DIAGNOSTICA, normal values <4 nmol/L). Patients with serially elevated CgA levels were requested to have fasting gut hormones and urinary 5-hydroxyindole acetic acid. CgA levels were elevated in 30.8% (n 1⁄4 12) of patients with IBD and 50.6% (n 1⁄4 44) of patients with D-IBS (P 1⁄4 0.04). The mean CgA levels in the IBD and IBS groups were 6.4 nmol/L and 7.2 nmol/L, respectively. Within the IBD group with elevated CgA (n 1⁄4 12/39), levels returned to normal in 2 patients on repeat testing. 8/12 had persistently elevated CgA but at a level less than 10 u/L. For the 2 patients who had a CgA >10 u/L, 1 patient had a normal octreoscan and computed tomography (CT) scan while the other patient declined repeat levels. In the D-IBS group, of the 44/87 who had CgA levels that were elevated, in 19/44 the CgA level normalized on repeat testing. Fifteen had repeat levels <10 nmol/L but with normal fasting gut hormones and urinary 5HIAA. In the 10/ 44 with levels >10 nmol/L subsequent carcinoid investigations were normal. Our study supports the observation of Sciola et al of elevated serum chromogranin A in IBD but also demonstrates that elevated levels occur more frequently in D-IBS patients. Could the unifying hypothesis be enterochromaffin cell hyperplasia resulting in elevated serum chromogranin A levels? The differential replication of the enterochromaffin cells in IBS patients could also explain why elevated levels are only found in a proportion of patients and levels decline with time. Further studies of serial serum chromogranin A measurements in both of these conditions would strengthen our understanding of the plausible mechanisms behind these observations.

Clinical utility of capsule endoscopy in patients with Crohn's disease and inflammatory bowel disease unclassified.

Background Although small bowel capsule endoscopy (SBCE) has developed an established role in Crohn’s disease (CD), there is paucity of data on impact of SBCE on subsequent management. We investigated the clinical utility of SBCE in patients with suspected and established CD and inflammatory bowel disease unclassified (IBDU). Materials and methods Patients referred routinely from 2003 to 2009 with a diagnosis of IBDU, suspected or established CD were identified retrospectively. Data were collected for indications and findings at SBCE with subsequent follow-up. Results A total of 315 patients were identified. There were n=265 referred for suspected CD (of which n=37 had a prior diagnosis of IBDU) and n=50 with established CD. SBCE was suggestive of CD in 17% of the suspected CD group, 43% in the IBDU group and 66% in the established CD patients. In the suspected CD cohort, an eventual diagnosis of CD was made in 12% (n=31) after a mean follow-up of 15 months (range 1–84), resulting in a change of management in 90% (n=28/31). In patients with IBDU, the diagnosis of CD was made in 38% (n=14) after an average follow-up of 19 months (±2). In patients with established CD, management was altered in 73% of patients after SBCE. Conclusion There was a low diagnostic yield in patients referred with suspected CD although a diagnosis at SBCE was predictive of a clinical diagnosis in the majority after a mean follow-up of 15 months. A diagnosis of CD was more likely in the IBDU and established CD cohort. SBCE diagnoses changed management in the majority of patients.

Are lower gastrointestinal investigations necessary in patients with coeliac disease

Background Colonoscopy may be indicated in patients with coeliac disease who present with iron deficiency anaemia or in coeliac disease patients who have persisting diarrhoea despite being on a gluten-free diet. However, there are limited data to support this approach. Methods We prospectively recruited patients who were found to have coeliac disease, having been referred with newly diagnosed iron deficiency anaemia. We also recruited a second group of patients with known coeliac disease. These patients had persisting diarrhoea despite being on a gluten-free diet for 6 months. All patients had colonoscopy and were matched with controls (without coeliac disease) who had similar indications for colonoscopy. Results Ninety-eight consecutive new patients with coeliac disease and concurrent iron deficiency anaemia had colonoscopy performed. Twelve (12.2%) had pathology, three of which were carcinomas. This diagnostic yield was not significantly different from the findings in the control group 62/362 (17.1%) P=0.24. In coeliac disease patients with persisting diarrhoea (n=37), the diagnostic yield at colonoscopy was 1/37 (2.7%). This was significantly lower than our findings in the control group with chronic diarrhoea 55/390 (14%) P=0.05. Conclusion Colonoscopy should be considered in patients with coeliac disease (over the age of 45 years) who present with iron deficiency anaemia. Whilst, for coeliac disease patients with persisting diarrhoea (on a gluten-free diet) in the absence of sinister symptoms, a flexible sigmoidoscopy may be the initial investigation in order to exclude microscopic colitis. However, further larger prospective studies are required to evaluate this approach.

Blinded controlled trial comparing image recognition, diagnostic yield and management advice by doctor and nurse capsule endoscopists

Introduction The authors have previously shown that experience improves lesion identification1 in capsule endoscopy (CE) and that a nurse reader overcalled lesions but did not miss significant pathology.2 Diagnostic nurse endoscopy is widely accepted in the UK but there is little data regarding proficiency in diagnostic capsule endoscopy (CE). Methods Consecutive CE videos read and reported by the nurse were examined by the doctor and vice versa in a blinded fashion and differences were arbitrated by a panel of both participants and two additional experts. The nurse is an experienced conventional endoscopist who had preread over 200 CE procedures; the doctor had read over 2000 CE videos. Gut symptoms refer to abdominal discomfort ± altered bowel habit and symptoms ‘plus’ with ‘alarm’ features (clinical or other investigation). Findings were considered ‘insignificant’ if they did not contribute to diagnosis or management. Data was analysed using a paired t test. Results Indications (95 patients, mean age 55 years, 35 male) included obscure bleeding (n=44), symptoms ‘plus’ (24), symptoms (12), coeliac disease (7), Crohns disease (5) and other (3). The number of thumbnails did not differ (p=0.24) but the doctor read more quickly (17 vs 24 min, p<0.001). Of 262 landmarks recorded by both, 259 (99%) were identical (arbitrarily decided as within 10 frames). Diagnoses were made in 30 (32%) patients: both identified Crohns disease (n=9); NSAID enteropathy (6); active bleeding (4); coeliac disease (2); tumour (2); angioectasia, anastamotic ulcer, biopsy site, pouchitis and infectious enteropathy (1 each). The nurse, but not the doctor, commented on altered blood in the stomach felt by the panel to be significant. The doctor diagnosed an ulcerated Meckels diverticulum described by the nurse as an ulcerated stricture. A diverticulum was noted by the doctor but not the nurse in a patient presenting with anaemia who also had Crohns disease. Of 35 management decisions, 27 (77%) were identical. Of the remaining decisions, both nurse (n=2) and doctor (n=2) failed to suggest what the panel considered appropriate actions. The nurse suggested repeating CE after aspirin cessation when deemed unnecessary by the panel and both nurse (n=3) and doctor (n=1) suggested one form of endoscopy when another was felt more appropriate. Conclusion There was no difference in landmark recognition or diagnostic yield between an experienced nurse endoscopist and a doctor CE reader. Moreover, management advice was not demonstrably different and varied only in the advised use of different endoscopes to target areas of the small bowel, for which there is no evidence on which to base practice.

Magnetically steerable gastric capsule endoscopy is equivalent to flexible endoscopy in the detection of markers in an excised porcine stomach model: results of a randomized trial

BACKGROUND AND STUDY AIMS Capsule endoscopy is well tolerated but control of its movement is needed in order to visualize the whole gastric surface. Technological developments have produced an external magnet to allow manipulation of the capsule within the gastric cavity. The aim of this study was to compare magnetically steerable gastric capsule endoscopy (MSGCE) with flexible endoscopy for the detection of beads in a porcine stomach. MATERIALS AND METHODS Beads were sewn onto the mucosal surface of 12 ex vivo porcine stomachs. Each model was examined by flexible endoscopy and MSGCE by two blinded investigators. MSGCE was performed according to a protocol using positional changes and magnetic steering. Outcome measures were number and location of beads identified, and duration of procedure. RESULTS Flexible endoscopy identified 79 /90 beads (88 %), and MSGCE identified 80 /90 (89 %). The difference in sensitivities was 1.11 (95 % confidence interval 0.06 - 28.26). Thus, MSGCE was noninferior to flexible endoscopy. Mean examination times for flexible endoscopy and MSGCE were 3.34 minutes and 9.90 minutes, respectively. CONCLUSION MSGCE was equivalent to conventional flexible endoscopy in the detection of beads in a porcine stomach model.

Does magnetically assisted capsule endoscopy improve small bowel capsule endoscopy completion rate? A randomised controlled trial.

Background and study aims: Delayed gastric emptying is a significant factor in incomplete small bowel capsule examinations. Gastric transit could be hastened by external magnetic control of the capsule. We studied the feasibility of this approach to improve capsule endoscopy completion rates. Patients and methods: Prospective, single-center, randomized controlled trial involving 122 patients attending for small bowel capsule endoscopy using MiroCam Navi. Patients were randomized to either the control group (mobilisation for 30 minutes after capsule ingestion, followed by intramuscular metoclopramide 10 mg if the capsule failed to enter the small bowel) or the intervention group (1000 mL of water prior to capsule ingestion, followed by positional change and magnetic steering). Outcome measures were capsule endoscopy completion rate, gastric clarity and distention, relationship of body habitus to capsule endoscopy completion rate (CECR), and patient comfort scores. Results: 122 patients were recruited (61 each to the control and intervention groups: mean age 49 years [range 21 – 85], 61 females). There was no significant difference in CECR between the two groups (P = 0.39). Time to first pyloric image was significantly shorter in the intervention group (P = 0.03) but there was no difference in gastric transit times (P = 0.12), suggesting that magnetic control hastens capsular transit to the gastric antrum but does not influence duodenal passage. Gastric clarity and distention were significantly better in the intervention group (P < 0.0001 and P < 0.0001 respectively). Conclusions: Magnetic steering of a small bowel capsule is unable to overcome pyloric contractions to enhance gastric emptying and improve capsule endoscope completion rate. Excellent mucosal visualisation within the gastric cavity suggests this technique could be harnessed for capsule examination of the stomach.

Diagnostic yield of small-bowel capsule endoscopy in patients with iron deficiency anemia: does it affect management?

We read with interest the systematic review by Koulaouzidis et al, who alluded that the validity of small-bowel capsule endoscopy in patients with iron deficiency anemia (IDA) alone remains limited. They found that studies focusing solely on IDA had a diagnostic yield of 66%, and significant findings included vascular (31%), inflammatory (17.8%), and mass and/or tumor (7.95%) lesions. We would like to share our findings. From a cohort of 1324 patients with obscure GI bleeding who underwent small-bowel capsule endoscopy, we identified 971 patients (73%) with IDA. The diagnostic yield was 35% (n Z 342) in the IDA group in which vascular lesions made up 23% (n Z 225), the combination of erosions and ulcers another 25% (n Z 245), and small-bowel tumors 2% (n Z 16) of