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PubMed2006

Small bowel tumors.

WCE is a noninvasive diagnostic technique that visualizes the entire small intestine and identifies lesions in parts of the small bowel not reached by traditional endoscopy. Although further studies are needed to define the exact role of WCE for diagnosing and managing small bowel tumors, its sensitivity has been shown to be superior to PE and small bowel follow-through in regard to diagnosing patients who have obscure GI bleeding, the most common indication for capsule endoscopy in the authors' series of patients with documented small bowel tumors. As more material is published, capsule endoscopy likely will be confirmed to be the diagnostic procedure of choice in patients with suspected small bowel tumors.

Endoscopes, Gastrointestinal↗
PubMed2002

Endoscopy of the small bowel in inflammatory bowel disease.

With the heterogeneous clinical presentation of IBD, endoscopy plays an integral role in the initial diagnosis of Crohn's disease. Although radiographic tests are often supplemental in the evaluation of Crohn's disease, they previously had been the only modality available allowing for visualization of much of the small bowel. The advent of small bowel endoscopy allows for direct visualization, and often biopsy, of the small bowel, allowing for confirmation of diagnosing and extent of involvement. Currently, the only mode for obtaining biopsies from beyond the ligament of Treitz is via push enteroscopy or intraoperative enteroscopy. Knowing the extent of disease can also help explain recalcitrant symptoms or lack of response to certain therapies. With the advent of capsule endoscopy, endoscopic visualization of the entire small intestine is now possible with a relatively noninvasive test. Further advancements in capsule endoscopy may relegate push enteroscopy and intraoperative enteroscopy to those cases in which biopsies or therapy are required. In the future, total enteroscopy with new enteroscopes may become more widely available, allowing biopsies and therapy in all segments of the small intestine, without the need for operative intervention.

Crohn Disease↗
PubMed2006

Double-balloon enteroscopy: a descriptive study of 50 explorations.

AIM: To evaluate the utility of double-balloon enteroscopy for small-bowel disease. DESIGN: A prospective study of 50 consecutive enteroscopies performed from December 2004 to July 2005 to analyze diagnoses and treatments. PATIENTS: 44 patients (33 had undergone a previous capsule endoscopy) with indications for obscure digestive hemorrhage, angiodysplasia, Peutz-Jeghers syndrome, ulcer, suspected Crohn's disease, tumors, and refractory celiac disease. RESULTS: We carried out enteroscopy studies in 44 patients by the oral route and, in 6 additional patients, by both the oral and anal routes. We reached the ileon with the oral route in all cases but one (jejunal stenosis), and in 4 cases out of 7 with the anal route, with an average duration of 73 minutes. We found angiodysplasia in 19 cases, as well as NSAID-related enteropathy, Crohn's disease, diverticulosis, and Waldenström's disease. We performed biopsies in 31% of cases with diagnoses of adenocarcinoma, lymphangiectasia secondary to tumor in celiac disease, and Whipple's disease. We treated 19 patients with angiodysplasia (1 to 20 synchronous lesions) with argon, and 4 patients with polyps using polipectomy (sporadic polyps or Peutz-Jeghers syndrome). A retained capsule in one patient with stenosis was removed. CONCLUSIONS: Double-balloon enteroscopy is a useful and effective technique in the diagnosis and treatment of small intestine diseases, thus complementing capsule endoscopy. More studies are needed to analyze its impact on the management of this condition.

Capsules↗
PubMed2005

Visible small-intestinal mucosal injury in chronic NSAID users.

BACKGROUND & AIMS: Patients who regularly take nonsteroidal anti-inflammatory drugs (NSAIDs) have an increased risk for small-intestinal mucosal ulceration and bleeding, which may present as anemia of undetermined gastrointestinal origin or protein loss. The prevalence and severity of small-intestinal lesions remains unclear. Our aim was to assess the frequency of NSAID-induced small-bowel injury among chronic NSAID users. METHODS: Ambulatory patients with various types of arthritides who took NSAIDs daily (>3 mo duration) or took either acetaminophen alone or nothing were enrolled in the study. All patients fasted overnight and underwent wireless video capsule endoscopy. Two investigators, blind to therapy, reviewed each video beginning after the pylorus. Lesions were scored as normal, red spots, small erosions, large erosions, or ulcers. An ulcer was defined as a larger lesion with apparent depth and a definite rim. RESULTS: Forty-one patients, 36 men and 5 women, ages ranging from 22 to 66 years (mean age, 49.8 y) were analyzed including 21 chronic NSAID users and 20 control patients. Small-bowel injury was seen in 71% of NSAID users compared with 10% of controls (P < .001). Injury was mild (few or no erosions, absence of large erosions/ulcers) in 10 NSAID users compared with 2 controls. Five NSAID users had major (>4 erosions or large ulcers/ulcers) damage compared with none in the control group. There were no complications or problems with the capsule endoscopy procedure. CONCLUSIONS: Endoscopically evident small-intestinal mucosal injury is very common among chronic NSAID users. The role of endoscopically evident injury in unexplained iron-deficiency anemia and hypoalbuminemia among chronic NSAID users remains undetermined.

Adult↗
PubMed2005

Nonsteroidal antiinflammatory drugs and the small intestine.

PURPOSE OF REVIEW: The small intestine is a more common site for nonsteroidal antiinflammatory drug (NSAID) toxicity than the well-recognized effects on the stomach and duodenum. Although NSAID strictures and perforation are rare, two thirds of regular NSAID users may be prone to small bowel enteropathy. This review highlights this emerging issue in patients requiring antiinflammatory drugs. RECENT FINDINGS: NSAID enteropathy is a stepwise process involving direct mucosal toxicity, mitochondrial damage, breakdown of intercellular integrity, enterohepatic recirculation, and neutrophil activation by luminal contents, including bacteria. Unlike upper gastrointestinal toxicity, cyclooxygenase-mediated mechanisms are probably less important. Newer imaging modalities such as capsule endoscopy studies suggest that small bowel erosions may be common in nonselective NSAID users. Sulfasalazine and metronidazole may prove to be useful, therapeutic options for patients who cannot cease their NSAIDs. SUMMARY: NSAID toxicity to the small intestine is common. Useful research tools have been developed to measure intestinal inflammation and permeability indirectly, but these are not generally available to the clinician, although enteroscopy and capsule endoscopy may be helpful. Anemia or hypoalbuminemia are useful clues to NSAID enteropathy. Cessation of the drug is ideal; otherwise, there is experimental data to support the use of sulfasalazine and metronidazole. Animal models are unraveling new mechanisms for mucosal toxicity beyond the cyclooxygenase model.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2005

Double-balloon endoscopy.

PURPOSE OF REVIEW: Our strategy for small intestinal diseases has dramatically been brushed up with a novel technique, double-balloon endoscopy, which exhibits extremely better insertability and maneuverability compared with conventional methods. Double-balloon endoscopy has a potential to change radically the approach for the small intestinal diseases in the future. In this article, the publications on double-balloon endoscope will be reviewed. RECENT FINDINGS: A double-balloon endoscope can be inserted into deeper portions of the small intestine via both oral and anal approaches, and allows endoscopic observation as well as treatment for the entire small intestine without general anesthesia. Reports have been made on this method's safety and low frequency of complication: it is very useful for diagnosis and treatment of small intestinal diseases, including small intestinal bleeding, small intestinal tumor, stenosis of small intestine, and polyposis syndrome. SUMMARY: The development of double-balloon endoscopy enabled observation and treatment in the entire small intestine. The double-balloon endoscopy has a potential to be a standard of enteroscopy by replacing conventional push enteroscopy and intraoperative enteroscopy. In the near future, the double-balloon endoscopy, together with the capsule endoscopy, will be essential modalities for the management of small intestinal diseases.

Endoscopy, Gastrointestinal↗
PubMed2006

Modification of pepsinogen I levels and their correlation with gastrointestinal injury after administration of dexibuprofen, ibuprofen or diclofenac: a randomized, open-label, controlled clinical trial.

OBJECTIVE: To assess the effect of a 2-week treatment with dexibuprofen, in comparison with ibuprofen and diclofenac, on pepsinogen plasma concentrations and gastrointestinal mucosa, as well as the correlation of these changes with gastrointestinal mucosal injury. METHODS: 60 patients with rheumatologic disease in chronic therapy with NSAID, were included. After a 7-day run-in period patients were randomly assigned to receive a 14-day treatment with dexibuprofen (Group A; Day 1 - 3 = 400 mg t.i.d; Day 4 - 14 = 400 mg b.i.d.), ibuprofen (Group B; Day 1 - 3 = 800 mg t.i.d; Day 4 -14 = 800 mg b.i.d.) or diclofenac (Group C; Day 1 - 3 = 50 mg t.i.d; Day 4 - 14 = 50 mg b.i.d.). Upper gastrointestinal endoscopy (Day 15), capsule-endoscopy (Day 16, 7 patients of each group) and determination of pepsinogen plasma concentrations were performed (basal and Day 15). A semiquantitative scale was designed for the assessment of the gastrointestinal mucosa. RESULTS: No differences in plasma pepsinogen were found between treatment groups or gastrointestinal injury grades or between basal and post-therapy determinations. Dexibuprofen showed gastroduodenal mucosal injury in fewer patients (42.1%) than was the case with ibuprofen (5%; p = 0.003) and diclofenac (30%; p = N.S.). Dexibuprofen administration was also associated with more patients having no intestinal mucosal damage (42.86% vs. 28.7% in the diclofenac group and 14.29% in the ibuprofen group; p = 0.0175). The rate of clinical adverse events was similar in Groups A, B and C (28%, 38% and 34%). CONCLUSIONS: Dexibuprofen showed a lower rate of gastroduodenal and intestinal mucosal injury. This effect was not mediated by modifications of plasma pepsinogen levels.

Administration, Oral↗
PubMed2002

[Endoscopy of the small intestine without tube or enema? A video capsule makes it possible].

The diagnosis of unclear bleeding in the small bowel remains a gastroenterological problem. To date, the diagnostic approach routinely employed has been roentgen Sellink. With such newer techniques as magnetic resonance tomography (MRT) substantially more diagnostic information can now be obtained. A recent new development is capsule endoscopy, which is intended for use when conventional endoscopic examinations fail to identify the source of bleeding. Using this new option in the Ludwigshafen Klinikum the small bowel lesions were discovered in 81% of the 26 patients in whom they had been previously remained undetected. At present, the patients have to bear the cost of this examination themselves.

Capsules↗
PubMed2006

What we have learned from 5 cases of permanent capsule retention.

BACKGROUND: Capsule endoscopy allows the direct visualization of the entire small bowel. There is limited data on the clinical significance of permanent capsule retention. OBJECTIVE: Our purpose was to document the frequency, findings, risk factors, management, and outcomes of permanent capsule retention. DESIGN: Retrospective, case series. SETTING: Single tertiary referral center, outpatient. RESULTS: Permanent capsule retention occurred in 2% of our cases (5/245). The following pathologies caused insufficient capsule passage: adenocarcinoma in a patient with hereditary nonpolyposis colorectal cancer (1), idiopathic stenosis (1), stricturing Crohn's disease (2), and adhesions (1). Capsule retention lead to a symptomatic small-bowel obstruction in only 1 of these cases (0.4%). As a consequence, 2 cases had successful endoscopic retrieval; 3 cases required surgical intervention. Four of 5 patients had a clear clinical benefit resulting from the capsule findings or the secondary procedure. CONCLUSIONS: Permanent capsule retention is rare. Even though this event may lead to the necessity of an endoscopic or surgical intervention, a clear benefit for the patient in respect to the underlying disease resulted in 4 of 5 patients.

Aged↗
PubMed2006

Evaluation of deep small bowel involvement by double-balloon enteroscopy in Crohn's disease.

OBJECTIVES: Double-balloon enteroscopy (DBE) enables inspection of deep small bowel, and total small bowel examination can be performed by either antegrade or retrograde DBE. The aim of this study was to evaluate ileal involvement, which cannot be achieved using conventional colonoscopy, by DBE in patients with Crohn's disease. METHODS: From December 2003 to September 2005, a total of 44 patients with Crohn's disease underwent 53 examinations using DBE. RESULTS: Forty patients with Crohn's disease, seven women and 33 men, underwent DBE, and the ileum was investigated in 38 patients. There were 25 cases of ileitis, 2 of colitis, and 13 of ileocolitis. Jejunal lesions were found in two and ileal lesions proximal to the terminal ileum were found in 24 patients with Crohn's disease. DBE was superior to radiological study to detect aphthae, erosions, and small ulcers in the ileum. Small bowel stricture was demonstrated in six and nine patients with DBE and small bowel barium study (SBBS), respectively. An additional mucosal finding was demonstrated in one of the eight patients who underwent wireless capsule endoscopy, and one patient had a capsule removed by DBE that had become lodged because of an ileal stricture. One ileal perforation because of overtube balloon pressure occurred in 53 examinations of patients with Crohn's disease (1.9%). CONCLUSION: DBE is useful to evaluate small bowel lesions in patients with Crohn's disease; however, special attention should be paid to mesenteric longitudinal ulcers during insertion and the overtube balloon should not be inflated if a clear intestinal view is not possible.

Adult↗
PubMedDate not supplied

[Primary adenocarcinoma of jejunum with obscure gastrointestinal bleeding].

A case of primary small bowel adenocarcinoma is reported because of the rarity of this malignancy. Interestingly, the location of the tumour was in jejunum, instead of the most common site in duodenum. The clinical presentation was anemia, with positive fecal blood test, under antiaggregant platelet treatment for coronary heart disease, initially related to endoscopic evidence of erosive gastroduodenitis. The exacerbation of gastrointestinal bleeding during proton pump inhibitors therapy and the recurrence of abdominal pain caused careful investigation. The source of the obscure gastrointestinal bleeding had been achieved by wireless capsule endoscopy, because of not diagnostic findings of conventional upper endoscopy control, colonscopy, double contrast enteroclysis and selective arteriography. The primary definitive therapy was a radical resection of the jejunal neoplastic loop, important prognostic factor.

Adenocarcinoma↗
PubMed2006

The risk of retention of the capsule endoscope in patients with known or suspected Crohn's disease.

OBJECTIVES: Capsule endoscopy (CE) allows visualization of the mucosa of the entire small bowel and is therefore a potentially important tool in the evaluation of patients with known or suspected Crohn's disease (CD). However, small bowel strictures, which are not uncommon in Crohn's, are considered to be a contraindication to CE for fear of capsule retention. Our goal was to determine the risk of capsule retention in patients with suspected or known CD. METHODS: We retrospectively reviewed the records of 983 CE cases performed at three private gastroenterology practices between December 2000 and December 2003, and selected those with suspected or proven Crohn's. RESULTS: A total of 102 cases were identified in which CE was used in patients with suspected (N = 64) or known (N = 38) CD. Only one of 64 patients (1.6%) with suspected CD had a retained capsule. However, in five of 38 (13%) patients with known Crohn's, the capsule was retained proximal to a stricture. Of the five cases of retained capsules, three strictures were previously unknown. In four cases, the obstructing lesions were resected without complications, leading to complete resolution of the patient's underlying symptoms. One patient chose not to undergo surgery and has remained without an episode of small bowel obstruction for over 38 months. CONCLUSIONS: Capsule retention occurred in 13% (95% CI 5.6%-28%) of patients with known CD, but only in 1.6% (95% CI 0.2%-10%) with suspected Crohn's. A retained capsule may indicate unsuspected strictures in Crohn's that may require an unexpected, but therapeutic, surgical intervention. Patients and physicians should be aware of these potential risks when using CE in CD.

Adolescent↗
PubMed2006

Videocapsule endoscopy is useful for the diagnosis of intestinal lymphangiectasia.

We study two authentic cases of protein-losing enteropathy, the diagnosis of which was facilitated using Given M2A videocapsule endoscopy. The first case corresponded to a primary intestinal lymphangiectasia confirmed by jejunum biopsies and the second one to a protein-losing enteropathy with lymphatic abnormalities secondary to a chronic constrictive pericarditis. In the first case, the mucosa of jejunum presented with a diffuse oedematous aspect, whitish villi, white curved lines probably related to submucosal dilated lymphatics and lacteal juice. In the second case, capsule endoscopy showed oedematous aspect of jejunum mucosa associated with white curved lines similar to those observed in the first case. Videocapsule endoscopy is useful in cases of protein-losing enteropathy to identify presence of intestinal lymphangiectasia and to specify their localisation after ruling out other disorders liable to induce protein-losing gastrointestinal syndrome.

Adult↗
PubMed2006

[Intestinal perforation secondary to impaction of a retained endoscopic capsule].

We present the first documented case of intestinal perforation due to impaction of an endoscopic capsule. The capsule was used to investigate anemia in an 80-year-old woman and was retained in the intestinal lumen for 2 months without producing symptoms. The patient presented to the emergency service with sudden, intense, diffuse abdominal pain. Hollow viscus perforation was suspected and surgery was performed. The diagnosis was distal ileum perforation secondary to an impacted endoscopic capsule in an area of severe postsurgical adhesions under a subcostal cholecystectomy incision performed 10 years previously. After reviewing the literature, we believe it important to report this exceptional complication of capsule endoscopy and suggest the possible management of capsules retained in the digestive tract.

Aged, 80 and over↗
PubMed2004

Evidence of small-bowel involvement in hereditary hemorrhagic telangiectasia: a capsule-endoscopic study.

BACKGROUND AND STUDY AIMS: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal-dominant vascular disorder leading to telangiectases and arteriovenous malformations of the skin, mucosa, and viscera. Telangiectases in the upper gastrointestinal tract are known, but data regarding possible small-bowel involvement are scarce due to the technical difficulty of exploring the entire gastrointestinal tract. The aim of the present study was to use capsule endoscopy (CE) to determine the prevalence of small-bowel telangiectases in HHT patients. PATIENTS AND METHODS: From December 2001 to September 2002, 20 consecutive adult HHT patients at an interdepartmental HHT center were prospectively evaluated. All patients underwent esophagogastroduodenoscopy (EGD) followed by CE within 24 h. The telangiectases were scored according to commonly accepted criteria by two endoscopists and two observers of the video-capsule images, who were blinded to each other's findings. RESULTS: EGD revealed gastric telangiectases in 15 of the 20 patients (75 %), while CE demonstrated small-bowel involvement in 10 of 18 patients (56 %; images were not recorded for two patients due to battery failure). No preferential site for telangiectasia was found between the jejunum and the terminal ileum. All patients who were positive on CE were also found to have gastric involvement at EGD. Patients with small-bowel telangiectases were significantly older than those without (62.5 years vs. 45 years; P < 0.02). CONCLUSIONS: This study established a 56 % prevalence of small-bowel telangiectases in patients with HHT. This new endoscopic technique will probably change the etiological diagnosis of occult bleeding in HHT patients (which is too often attributed only to epistaxis) and may also be able to alter treatment strategies in HHT patients with gastrointestinal bleeding.

Adult↗
PubMed2006

Upper gastrointestinal bleeding.

PURPOSE OF REVIEW: This review provides an update on the management of upper gastrointestinal bleeding with special attention to patient preparation, sedation, hemostatic techniques, and postprocedure care. RECENT FINDINGS: In a large multicenter clinical trial, nurse-administered propofol sedation had a complication rate of less than 0.2%. The optimal management for an ulcer with adherent clot was confirmed by a meta-analysis to be clot removal and endoscopic treatment of the underlying lesion. A number of prospective studies have demonstrated that capsule endoscopy is the most sensitive imaging modality for identifying lesions in the small bowel and that double-balloon enteroscopy is the least invasive modality available for the management of these lesions. SUMMARY: This update describes many recent advances in the diagnosis and management of upper gastrointestinal bleeding. However, clearly, much work needs to be done in this field. Since propofol is not available for use in all endoscopy units, is there a better alternative for deep sedation? Rebleeding occurs in 20% of patients after endoscopic therapy, and so can we provide better outcomes with newer technologies (endoscopic suturing devices)? Finally, what is the best management for Helicobacter pylori-negative, nonsteroidal antiinflammatory drug-negative ulcer patients?

Capsule Endoscopy↗