Simon Panter

Tracheal Aspiration of a Capsule Endoscope: Not Always a Benign Event

To the Editor, We read with great interest the report and compilation of cases of capsule endoscope (CE) aspiration by Lucendo et al. [1] and also the correspondence from Koulaouzidis et al. [2] reporting a further 2 cases of aspiration and recommending use of real time viewer (RTV) in the immediate post-ingestion period. We would like to add a further case to complete the compilation. The case occurred in a 77 year-old-lady with a history of iron deficiency, abdominal pain and weight loss. The only past medical history was a hysterectomy. She had previously been investigated with an oesophagoduodenoscopy (OGD) and duodenal biopsies and a colonoscopy, which other than the presence of a small hiatus hernia were all normal. There was no history of dysphagia or pharyngeal disorder. Ingestion of the capsule was attempted but caused a choking episode, resulting in the capsule being coughed up. Endoscopic placement of the capsule was then arranged using the advanCE device. This was carried out unsedated and without incident; there were no significant haemodynamic changes or changes in oxygenation noted during the procedure. On return to the ward, the patient was noted to have developed slurred speech which gradually progressed with right-sided limb and facial weakness. An urgent CT head was performed which showed extensive haemorrhage into the right frontal and parietal lobes, with marked associated mass effect and midline shift. The case was discussed with the regional neurosurgical team at the tertiary referral centre and the patient was intubated for transfer. She was assessed by the neurosurgical team on arrival and it was felt that intervention was not in the patient’s best interests; she died soon after. This case adds to the growing recognition that capsule aspiration is a potential hazard. There have been multiple previously published cases of CE aspiration [3–14]. A recent case compilation and literature review by Lucendo et al. [1] looked at documented cases and concluded that aspiration could occur in at least 1 in 800 cases, especially in elderly patients, and is usually considered a benign event. In this case, we presume the mechanism of intracerebral haemorrhage (ICH) to be related to rupture of a cerebral aneurysm as a result of increased intracranial pressure, either as a result of the coughing bout due to aspiration of the CE or related to the endoscopy used to place the capsule, demonstrating that these aspirations are not always benign. Previous cases of capsule aspiration have noted that aspirations are more frequent in patients with a weak or absent cough. This patient had no obvious reason to be at risk of aspiration, and we would agree with Koulaouzidis et al. [2] in their suggestion for confirmation of CE position with RTV shortly after ingestion. We would take this further and suggest that, in high risk patients, the safest approach may be to directly place the capsule into the duodenum. This is the first case to document fatality due to ICH following possible capsule aspiration and endoscopic capsule placement, questioning the assumption that CE aspiration is a benign event.

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

Capsule endoscopy--not just for the small bowel: a review.

Video capsule endoscopy is being increasingly used to investigate the esophagus and colon as well as the small bowel. With the advancement of technology used in capsule endoscopy there have been marked improvements in diagnostic rates for colon capsule endoscopy in the detection of colonic polyps and colorectal cancer. It is also being increasingly used in the field if inflammatory bowel disease to investigate for mucosal inflammation and could potentially be used to assess mucosal healing. It also has role in completing the evaluation of colonic pathology in those in whom colonoscopy is incomplete. Esophageal capsule is preferred by patients over esophagogastroduodenoscopy (EGD) but as yet does not rival EGD in terms of diagnostic accuracy however the advent of magnetically steerable capsules may improve this. This review covers advances in the field of colon and esophageal capsule endoscopy; it covers diagnostic capabilities of these 2 tools as well as technical aspects of both procedures and preparation.

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.

Patient-derived measures of GI endoscopy: A meta-narrative review of the literature

BACKGROUND AND AIMS GI endoscopy (GIE) is widely performed, with 1 in 3 people requiring an endoscopic procedure at some point. Patient experience of medical procedures is important, but, to date, experience measures of GIE are derived from clinician opinion rather than from patients themselves. In this meta-narrative review, the literature on methods of assessing patient experience in GIE is reported. METHODS ScienceDirect, MEDLINE, Web of Knowledge, Web of Science, CINAHL, and PsycINFO were searched to November 2013 using meta-narrative standards. Search terms included those related to endoscopic procedures, combined with those related to patient experience. RESULTS A total of 3688 abstracts were identified and reviewed for relevance. A total of 3549 were excluded, leaving 139 for full-text review. We subsequently included 48 articles. Three sub-groups of studies were identified--those developing original measures of endoscopy-specific patient experience (27 articles), those modifying existing measures (10 articles), and those testing existing measures for reliability or validity (11 articles). Most measures focused on pain, discomfort, anxiety, and embarrassment. Three studies explored wider aspects of experience, including preparation, unit organization, and endoscopist preference. Likert scales, visual analog scale scores, and questionnaires were used most commonly. The Global Rating Scale was validated for use in 2 studies, confirming that those domains cover all aspects of endoscopy experience. Other measures were modified to assess endoscopic experience, such as the modified Group Health Association of America survey (mGHAA-9) (modified by 5 studies). CONCLUSIONS No patient-derived and validated endoscopy-specific experience measures were found. Patient-derived and validated experience measures should be developed and used to model optimal healthcare delivery.

Terminal ileal intubation and biopsy in routine colonoscopy practice

This special report focuses on the current literature regarding the utility of terminal ileal (TI) intubation and biopsy. The authors reviewed the literature regarding the clinical benefit of TI intubation at the time of colonoscopy and also the evidence for TI intubation as a colonoscopy quality indicator. TI intubation is useful to identify ileal diseases such as Crohn’s disease and additionally as a means of confirming colonoscopy completion when classical caecal landmarks are not confidently seen. Previous studies have demonstrated that TI intubation has variable yield but may be more useful in patients presenting with diarrhea. Reported rates of TI intubation at colonoscopy vary. The authors demonstrate that terminal ileoscopy is feasible in clinical practice and sometimes yields additional clinical information. Additionally it may be used as an indicator of colonoscopy completion. It may be particularly helpful when investigating patients with diarrhea, abnormalities seen on other imaging modalities and patients with suspected Crohn’s disease. TIs reported as normal at endoscopy have a low yield when biopsied; however, biopsies from abnormal-looking TIs demonstrate a higher yield and have greater diagnostic value.

Training in Capsule Endoscopy: Are We Lagging behind?

Capsule endoscopy (CE) is a new modality to investigate the small bowel. Since it was invented in 1999, CE has been adopted in the algorithm of small bowel investigations worldwide. Reporting a CE video requires identification of landmarks and interpretation of pathology to formulate a management plan. There is established training infrastructure in place for most endoscopic procedures in Europe; however despite its wide use, there is a lack of structured training for CE. This paper focuses on the current available evidence and makes recommendations to standardise training in CE.

Postoperative methicillin-resistant Staphylococcus aureus enteritis following hysterectomy: a case report and review of the literature.

Following a hysterectomy a 43-year-old woman developed colicky abdominal pain and profuse postoperative diarrhoea. Examination was unremarkable and initial investigations revealed a normal plain abdominal X-ray initially, but later there was some small bowel dilatation and evidence of raised inflammatory markers. No cause was identified at exploratory laparotomy 2 days post operation. Flexible sigmoidoscopy was normal. The patient was empirically treated with oral vancomycin for presumed Clostridium difficile diarrhoea, although subsequent stool cultures were negative for the usual intestinal pathogens and C. difficile toxin. The diarrhoea persisted for 9 days. By day 10 stool cultures had grown methicillin-resistant Staphylococcus aureus, establishing the diagnosis. To our knowledge this is the first report of methicillin-resistant S. aureus enteritis following hysterectomy.

Small Bowel Capsule Endoscopy

Although optical technology in the gastrointestinal tract has much improved in the last decade, image quality is only as good as the preparation achieved. As current capsule technology does not allow suctioning or flushing of fluid from the surface of the small bowel mucosa, there is consequently a greater imperative for adequate preparation to optimise detection of any potential lesion by the capsule endoscope.

Transnasal endoscopy: no gagging no panic!

Background Transnasal endoscopy (TNE) is performed with an ultrathin scope via the nasal passages and is increasingly used. This review covers the technical characteristics, tolerability, safety and acceptability of TNE and also diagnostic accuracy, use as a screening tool and therapeutic applications. It includes practical advice from an ear, nose, throat (ENT) specialist to optimise TNE practice, identify ENT pathology and manage complications. Methods A Medline search was performed using the terms “transnasal”, “ultrathin”, “small calibre”, “endoscopy”, “EGD” to identify relevant literature. Results There is increasing evidence that TNE is better tolerated than standard endoscopy as measured using visual analogue scales, and the main area of discomfort is nasal during insertion of the TN endoscope, which seems remediable with adequate topical anaesthesia. The diagnostic yield has been found to be similar for detection of Barretts oesophagus, gastric cancer and GORD-associated diseases. There are some potential issues regarding the accuracy of TNE in detecting small early gastric malignant lesions, especially those in the proximal stomach. TNE is feasible and safe in a primary care population and is ideal for screening for upper gastrointestinal pathology. It has an advantage as a diagnostic tool in the elderly and those with multiple comorbidities due to fewer adverse effects on the cardiovascular system. It has significant advantages for therapeutic procedures, especially negotiating upper oesophageal strictures and insertion of nasoenteric feeding tubes. Conclusions TNE is well tolerated and a valuable diagnostic tool. Further evidence is required to establish its accuracy for the diagnosis of early and small gastric malignancies. There is an emerging role for TNE in therapeutic endoscopy, which needs further study.