Sarah Douglas

Fecal calprotectin: A selection tool for small bowel capsule endoscopy in suspected IBD with prior negative bi-directional endoscopy

Abstract Background and aim. Fecal calprotectin (FC) is a non-invasive marker of gastrointestinal inflammation with advocated diagnostic precision in distinguishing inflammatory bowel disease (IBD) from non-IBD diagnoses. FC correlates with abnormalities seen on small bowel barium radiology, but little data exist in relation with small bowel capsule endoscopy (SBCE). To investigate the value of FC as a selection tool for further investigation of the small bowel with SBCE, in a cohort of patients who had negative bi-directional endoscopies, but with continuing clinical suspicion of Crohns disease (CD). Methods. We retrospectively correlated the findings of SBCE with FC levels in patients referred with clinical suspicion of CD and negative bi-directional endoscopies. Only patients with FC results prior to the SBCE test were included; in cases of multiple FC determinations, the value closest to the SBCE date was selected. Medications history including usage of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) was made available for all patients. SBCE findings were analyzed against final diagnosis and FC values. Results. Seventy adult patients were studied (53 females, 17 males). Three cases were excluded, due to capsule retention in the stomach. Median time from FC measurement to SBCE was 62 days. Twenty-three patients had normal FC (≤50 μg/g) and in all those the SBCE was normal. Forty-four patients had FC >50 μg/g; in this group, nine patients had FC between 51 and 100 μg/g and all had a normal SBCE. Thirty-five patients had FC levels >100 μg/g; of those, 15 (42.85%) had SBCE findings compatible with CD and mean FC levels 326 μg/g (range 116–1430 μg/g). A definitive clinical diagnosis of CD, based on subsequent follow-up, was made in 10/35 (28.5%) of patients. These 10 patients were within the subgroup of 15 patients with positive SBCE findings and had median FC levels 368 μg/g (range 235–1430 μg/g). Conclusions. Measurement of FC levels prior to referral for SBCE is a useful tool to select patients with possible small bowel CD. A FC >100 μg/g is good predictor of positive SBCE findings, while FC >200 μg/g was associated with higher SBCE yield (65%) and confirmed CD in 50% of cases. Patients with FC between 50 and 100 μg/g had normal SBCE, despite symptoms suggestive of IBD. In all patients with clinical suspicion of CD and negative bi-directional endoscopies, FC assessment should be carried out prior to their referral for SBCE. Where FC is <100 μg/g (NPV 1.0), SBCE is not indicated.

The use of small-bowel capsule endoscopy in iron-deficiency anemia alone; be aware of the young anemic patient.

Abstract Background & aim. The role of Small-Bowel Capsule Endoscopy (SBCE) in Iron Deficiency Anemia (IDA) alone is still under validation. We aim to assess the usefulness of SBCE in patients with IDA alone; Methods. Retrospective study; patients with IDA (no GI symptoms or known previous diagnosis), who underwent SBCE were included. SBCE findings were classified as clinically significant/sinister (small-bowel malignancy, significant/sinister inflammation and/or strictures and coeliac disease) or vascular, i.e., signifcant/angioectasias (P1/P2 lesions); Results. A total of 221 (151F/70M) patients had SBCE for IDA as the sole indication. The diagnostic yield (DY) was 30.7% (68/221). The DY for significant/sinister pathology and significant/angioectasias was 9% and 21.7%, respectively. In those ≤40 years (20; 13F/7M), significant pathology was found in 25% (5/20); in the >40-year group (201; 138F/63M), significant/sinister pathology was found in 7.5% (15/201), p = 0.0231. None of the patients ≤40 years had angioectasias, such lesions were found in 48/201 (21.7%) of those >40 years, p = 0.009. Fifty percent of those >80 years (16; 12F/4M) had angioectasias, but none had significant/sinister pathology (p = 0.0126). On multiple regression analysis, only prior blood transfusion was predictive of higher DY in SBCE; Conclusions. IDA alone is one of the main indications (27%) for referral to SBCE; the majority of patients are >40 years. In our cohort, the DY of SBCE for IDA was 30.7% and the commonest finding was angioectasias. The detection rate of sinister small-bowel pathology for those >40 years is low decreasing to zero in the >80 age group. In contrast, 25% of those ≤40 years had a sinister diagnosis.

Chromoendoscopy in small bowel capsule endoscopy: Blue mode or Fuji Intelligent Colour Enhancement?

INTRODUCTION Virtual chromoendoscopy is used to enhance surface patterns and colour differences. One type of virtual chromoendoscopy is the Fuji Intelligent Colour Enhancement (FICE). Although widely applied in conventional endoscopy, data on FICE application in capsule endoscopy are limited. Furthermore, the validity of Blue filter (feature of RAPID(®) software) has not been examined. AIM/S: We aimed to qualitatively evaluate the use of FICE and Blue filter enhancement, in images of lesions obtained during small bowel capsule endoscopy, comparing them with similar, conventional (white light) images. METHODS A total of 167 images (6 different lesion categories) obtained from 200 capsule endoscopy examinations. Two gastroenterologists examined the images with white light, FICE and Blue filter in regards to the visibility of blood vessels, the contrast of the mucosal surface, and the demarcation of lesion borders. The agreed scores were: improved, similar, worse. Inter-observer agreement was calculated. RESULTS For all lesion categories, Blue filter provided image improvement (compared to white light) in 83%, (inter-observer agreement: 0.786). With FICE 1, improvement was observed in 34%, worse image in 55.9%, (inter-observer agreement: 0.646). With FICE 2, improvement was observed in 8.6%, worse in 77.5%, (inter-observer agreement: 0.617). With FICE 3, improvement was seen in 7.7%, worse in 79.9% (inter-observer agreement: 0.669). CONCLUSION Comparing with FICE, Blue filter offers better image enhancement in capsule endoscopy.

Three-dimensional representation software as image enhancement tool in small-bowel capsule endoscopy: a feasibility study.

BACKGROUND Three-dimensional imaging in capsule endoscopy is not currently feasible due to hardware limitations. However, software algorithms that enable three-dimensional reconstruction in capsule endoscopy are available. METHODS Feasibility study. A phantom was designed to test the accuracy of three-dimensional reconstruction. Thereafter, 192 small-bowel capsule endoscopy images (of vascular: 50; inflammatory: 73; protruding structures: 69) were reviewed with the aid of a purpose-built three-dimensional reconstruction software. Seven endoscopists rated visualisation improved or non-improved. Subgroup analyses performed for diagnostic category, diagnosis, image surface morphology and colour and SBCE equipment used (PillCam(®) vs. MiroCam(®)). RESULTS Overall, phantom experiments showed that the three-dimensional reconstruction software was accurate at 90% of red, 70% of yellow and 45% of white phantom models. Enhanced visualisation for 56% of vascular, 23% of inflammatory and <10% of protruding structures was noted (P=0.007, 0.172 and 0.008, respectively). Furthermore, three-dimensional software application enhanced 53.7% of red, 21.8% of white, 17.3% of red and white, and 9.2% of images of lesions with colour similar to that of the surrounding mucosa, P<0.0001. CONCLUSIONS Application of a three-dimensional reconstruction software in capsule endoscopy leads to image enhancement for a significant proportion of vascular, but less so for inflammatory and protruding lesions. Until optics technology allows hardware-enabled three-dimensional reconstruction, it seems a plausible alternative.

QuickView in small-bowel capsule endoscopy is useful in certain clinical settings, but QuickView with Blue Mode is of no additional benefit.

Background Analysis of small-bowel capsule endoscopy (SBCE) is time-consuming. QuickView (QV) has been added to the RAPID software to reduce the reading times. However, its validity is still under intense review. Recently, we have shown that Blue Mode (BM) provides improvements in images for most lesion categories. Aim To assess the validity of QuickView with white light (QVWL) and QuickView with Blue Mode (QVBM) reading, in a group of patients who underwent SBCE in our centre, by comparing it with the standard video sequence review (used as reference) by experienced SBCE readers. Methods This was a retrospective study; all SBCE (August 2008–November 2011), performed with PillCam SB, with complete small-bowel visualization were included. A clinician with previous SBCE experience, unaware of the SBCE reports, reviewed prospectively the video streams on RAPID platform using QVWL and QVBM. All SBCE had been reported previously using the standard mode; these reports were considered as the reference. There were 106 cases of obscure gastrointestinal bleeding (OGIB), 81 cases of known or suspected Crohn’s disease (CD) and 10 cases of polyposis syndromes. Results The mean small-bowel evaluation was 475 (±270) s and 450 (±156) s for QVWL and QVBM, respectively. In the OGIB (n=106; 21 overt/85 occult), with QVWL, 54 [P0 (28), P1 (18), P2 (8)] lesions were detected, 63 [P0 (48), P1 (13), P2 (2)] with QVBM, as compared with 98 [P0 (67), P1 (23), P2 (8)] by standard (reference) reporting. For P1+P2 lesions, the sensitivity, specificity, positive predictive value and negative predictive value for QVWL (as compared with reference reporting) were 92.3, 96.3, 96 and 92.8%, respectively. For QVBM, the above values were 91, 96, 96.2 and 90.6%, respectively. Eighty-one (n=81) patients underwent SBCE for small-bowel evaluation on the basis of a clinical history of suspected or known CD. With QVWL, 71 mucosal ulcers were detected, 68 with QVBM, as compared with 155 mucosal ulcers with reference reading. Finally, in the polyposis category with QVWL and QVBM, four polypoid lesions were detected compared with seven with standard (reference) review. Conclusion QV can be used confidently in OGIB in an urgent inpatient setting and in outpatients with occult OGIB or suspected CD. Furthermore, BM does not confer any additional advantage in the QV setting. Standard review settings should be used in all other cases.

Aspiration of video capsule: rare but potentially life-threatening complication to include in your consent form.

Aspiration of Video Capsule: Rare but Potentially Life-Threatening Complication to Include in Your Consent Form

The use of domperidone increases the completion rate of small bowel capsule endoscopy: does this come at the expense of diagnostic yield?

Background: The completion rate (CR) of small bowel capsule endoscopy (SBCE) has been reported at 81.3% to 84.8%. Prokinetic agents are used to increase CR and (theoretically) diagnostic yield (DY). Domperidone has not been widely used in SBCE; unlike metoclopramide, it lacks extrapyramidal adverse effects. Objectives: This was a retrospective study. This study aimed to assess gastric transit time (GTT), small bowel transit time (SBTT), and the CR of SBCE when using domperidone. Furthermore, we aimed to compare the CR of 2 different SBCE systems (MiroCam, PillCam). Consecutive SBCE examinations (January 2008 to October 2012) from a tertiary referral center were analyzed. Results: In the aforementioned period, a total of 635 SBCE examinations were performed: 379/635 (59.7%) with PillCamSB and 256 (40.3%) with MiroCam. In 437/635 (68.8%) examinations, liquid domperidone (5 mg) was administered for capsule ingestion, whereas 198 (31.2%) ingested the capsule without any domperidone. Although the 2 groups were comparable, the median age of patients who received domperidone was higher compared with patients who did not receive (58 vs. 48 y, P=0.027). In our cohort, the overall CR of SBCE was 88.9%. The 2 SBCE systems showed equivalent CR (PillCamSB 88.9%, MiroCam 89.1%; P =0.96). The use of liquid domperidone increased CR (91.1% vs. 84.3%; P =0.042). Interestingly, the use of domperidone with PillCamSB was associated with reduced DY for vascular, inflammatory, and polyps/mass-type lesions. This effect was not seen in the MiroCam group. Furthermore, the median GTT and the median SBTT did not differ between the 2 groups (GTT/SBTT with domperidone 26.0′/221.0′ and without 29.0′/228.0′, respectively; P=0.461/P=0.477). A higher CR was noted when domperidone was used with PillCamSB (93.0% vs. 89.5%, P=0.012) than with MiroCam (84.4% vs. 83.3%, P=0.08). Limitations: The major limitations of this study were the retrospective design of the study and limited numbers on MiroCam with no domperidone. Conclusions: In conclusion, the use of domperidone increases the CR of SBCE with PillCamSB. However, this increase does not translate into higher DY. A smart, tailored approach, which may include domperidone, purgatives, and real-time viewers, may be used in the clinical practice to improve DY until technology delivering capsules with much longer battery time becomes available.

Identification of the ampulla of Vater during oesophageal capsule endoscopy: two heads and viewing speed make a difference.

We read with great interest the recent study of Selby and Prakoso [1], investigating the abilities of capsule endoscopy (CE; Pillcam, Given Imaging, Yoqneam, Israel) in the identification of the ampulla of Vater (AoV). AoV identification is considered, by most CE readers, a good surrogate marker of detection of small bowel polyps. This is particularly relevant in the investigations of patients with familial adenomatous polyposis syndromes, which present an increased frequency of periampullary lesions.

Heads or Tail Orientation in Small-Bowel Capsule Endoscopy: 2 Capsule Models with 2 Reviewers

We read with great interest the article by Kopylov et al. [1] on the orientation of the small-bowel capsule endoscope’s (CE) movement in the small bowel. Although factors determining the orientation of a CE during a small-bowel study—and thus the diagnostic yield—are complex and largely due to random chance, this study represents an important attempt to highlight the importance of capsule passage orientation when imaging the small-bowel. The authors have also clearly demonstrated (using submersion testing) that the PillCam SB2 capsule has its center of gravity closer to the antenna dome due to the heavier battery compartment. In our center, we use two CE systems, i.e., Given Imaging PillCam and Intromedic Ltd MiroCam . We aimed to determine how the MiroCam capsules compared to PillCam in orientation of small-bowel movement. We therefore repeated the submersion experiment by immersing a PillCam SB2 and a MiroCam in a glass of plain tap water. It was noted that the PillCam replicated the previous experiment by orientating its antenna’s dome first. However, the MiroCam lay horizontally on the bottom of the glass (Fig. 1). As Kopylov et al. point out, previous data suggest that that the vector of CE small-bowel transit impacts on the CE diagnostic yield [2]. It has been shown that single-headed CE may have limitations when compared to double-headed CE [3, 4], in the detection of anatomical landmarks, i.e., ampulla of Vater. We have recently reported our center’s experience with two different small-bowel capsule endoscopy systems [5]. Review of our dual system small-bowel capsule endoscopy (SBCE) patient database was performed and all SBCE with either suboptimal image quality due to poor preparation or technical failures, i.e., inability to retrieve video-sequences stored in compact disks due to time corruption and/or incomplete recording were excluded. The remaining 17 patients have been investigated multiple times with both CE systems at different points in their diagnostic work-up totaling 20 PillCam procedures and 18 MiroCam procedures. The indications for SBCE were: obscure (overt/ occult) gastrointestinal bleeding (n = 13), Crohn’s (known/suspected) disease assessment (n = 4). Both reviewers (AK, reviewer 1 and SD, reviewer 2) have extensive experience with CE. We re-examined the SBCE aiming to detect the direction (heador tail-first) of each CE system through the pylorus and the ileocecal valve as suggested by Kopylov et al. [1]. In the PillCam cohort, the pylorus was entered head-first in 13/20 (65%) and 14/20 (70%) examinations, for reviewer 1 and 2, respectively. The head-first direction of transit through the IC valve was seen in 14/20 (70%) and 15/20 (75%) examinations, for reviewer 1 and 2, respectively. In the MiroCam group, the head-first pyloric entry was recorded in 13/18 (72%) and 14/18 (78%) examinations, for reviewer 1 and 2, respectively. For the IC head-first transit, the values were 14/18 (78%) and 11/18 (61%), respectively (Fig. 2). The interobserver variability was quantified by the Cohen’s kappa (j) unweighted statistic, which measures over and above chance agreement. Statistical analyses were carried out with a statistical package program for Windows (StatsDirect version 2.7.8 Software, StatsDirect Ltd, Altrincham, Cheshire, UK). Kappa values of \0, 0–0.2, 0.21–0.4, 0.4–0.75, and [0.75 were considered to indicate A. Koulaouzidis (&) S. Douglas J. N. Plevris Endoscopy Unit, Centre for Liver and Digestive Diseases, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK e-mail: akoulaouzidis@hotmail.com

Capsule endoscopy in clinical practice: concise up-to-date overview

Until recently, the small bowel was considered a ‘no man’s land’ as the imaging modalities available for its investigation were laborious, invasive, costly, or involve significant radiation exposure. Wireless capsule endoscopy (WCE) has changed the field dramatically, over the last eight years. The established indications for small bowel WCE are obscure gastrointestinal bleed/anemia, Crohn’s disease, hereditary polyposis syndromes, and to a lesser extent, evaluation of side effects of nonsteroidal anti-inflammatory medications and coeliac disease. We herein present an overview of the capsule examination, which seems to be a quickly improving area.