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PubMed2006

Preparations and prokinetics.

The evaluation of the importance of bowel preparations, prokinetics and postural tricks for bowel cleanliness, completeness of evaluation, and ultimately for the diagnostic yield of VCE is hampered by several factors. First, most studies are published in abstract form. Second, the methodological quality of the studies is rather low, because randomized comparisons are only a small minority. Third,there is no accepted and validated scale to evaluate bowel cleanliness. For all of these reasons, comparisons between studies are very difficult, and drawing general conclusions is almost impossible. As a consequence, at the Fifth International Conference on Capsule Endoscopy [9], only a limited measure of consensus could be reached on the fact that preparations/prokinetics probably improve the quality of small bowel cleanliness. It also was agreed that it is possible that preps/prokinetics improve GTT, SBTT and completeness of examination, and that keeping the patients recumbent in the right lateral position may shorten the GTT. It was noted, however, that the best type of preparation, and dose and time of administration remain to be determined. Additionally, data on prokinetics and postural tricks are insufficient to reach a firm conclusion. Unanswered questions concern the effect of medications on the diagnostic yield of VCE, whether prokinetics increase the miss rate, whether preparations/prokinetics cause adverse effects and the influence of medications on patient acceptance.

Endoscopes, Gastrointestinal↗

PubMed2006

Intestinal tract injury by drugs: Importance of metabolite delivery by yellow bile road.

Drug secretion into bile is typically considered a safe route of clearance. However, biliary delivery of some drugs or their reactive metabolites to the intestinal tract evokes adverse consequences due to direct toxic actions or indirect disruption of intestinal homeostasis. Biliary concentration of the chemotherapy agent 5-fluorodeoxyuridine (FUDR) and other compounds is associated with bile duct damage while enterohepatic cycling of antibiotics contributes to the disruptions of gut flora that produce diarrhea. The goal of this review is to describe key evidence that biliary delivery is an important factor in the intestinal injury caused by representative drugs. Emphasis will be given to 3 widely used drugs whose reactive metabolites are plausible causes of small intestinal injury, namely the nonsteroidal anti-inflammatory drug (NSAID) diclofenac, the immunosuppressant mycophenolic acid (MPA), and the chemotherapy agent irinotecan. Capsule endoscopy and other sensitive diagnostic techniques have documented a previously unappreciated, high prevalence of small intestinal injury among NSAID users. Clinical use of MPA and irinotecan is frequently associated such severe intestinal injury that dosage must be reduced. Observations from clinical and experimental studies have defined key events in the pathogenesis of these drugs, including roles for multidrug resistance-associated protein 2 (MRP2) and other transporters in biliary secretion and adduction of enterocyte proteins by reactive acyl glucuronide metabolites as a likely mechanism for intestinal injury. New strategies for minimizing the adverse intestinal consequences of irinotecan chemotherapy illustrate how basic information about key events in the biliary secretion of drugs and the nature of their proximate toxicants can lead to safer protocols for drugs.

Animals↗

PubMed2003

Acute small bowel bleeding: a distinct entity with significantly different economic implications compared with GI bleeding from other locations.

BACKGROUND: Historically, acute lower intestinal bleeding has incorporated small bowel with colonic sources. This potentially obscures the unique characteristics of small bowel bleeding, which are eclipsed by the attributes of the much more common colonic bleeding. Separating acute lower intestinal bleeding into small bowel and colonic sources may delineate characteristics of each, thereby making it possible to determine whether clinical outcomes vary by anatomic level of bleeding. METHODS: A total of 29 consecutive patients (15 women, 14 men; age 68.6 +/-2.4 years) with acute small bowel bleeding were compared with two other groups, each with 29 consecutive patients, with either acute colonic bleeding or acute upper GI bleeding. Clinical presentation, outcomes, and resource utilization for small bowel bleeding were compared with similar parameters for acute colonic bleeding and upper GI bleeding. RESULTS: Although the clinical presentation did not always distinguish the 3 groups, resource utilization was significantly higher in the small bowel bleeding group. The latter group required a higher number of diagnostic procedures (p < 0.001) and blood transfusions (p < 0.001), remained in hospital longer (p < 0.05), and had a higher cost of hospitalization (p < 0.001) compared with the colonic bleeding and upper GI bleeding groups. The mortality rate for patients with small bowel bleeding was 10%. Although none of the patients with upper GI bleeding and only 14% of those with colonic bleeding required greater than 3 diagnostic procedures, 79% of patients with small bowel bleeding required 4 procedures for diagnostic localization (p < 0.0001). CONCLUSIONS: Small bowel bleeding ("mid-intestinal bleeding") is a distinct clinical entity with significantly worse outcomes compared with colonic bleeding and upper GI bleeding. The focus of the investigation should be directed to the small bowel, with enteroscopy or capsule endoscopy, when 3 investigative procedures fail to localize recurrent overt GI bleeding.

Acute Disease↗

PubMed2006

[Acute "difficult" gastrointestinal bleeding].

Gastrointestinal bleeding with its point of origin outside the reach of conventional gastro- and colonoscopy represents an extraordinary diagnostic and therapeutic challenge. Bleeding may originate from the small bowel distal to the duodenojejunal junction (middle gastrointestinal bleeding) or from the biliary tree (haemobilia) or from the pancreatic ductal system (haemosuccus pancreaticus). This particular type of gastrointestinal bleeding is often intermittend and caused by a variety of different pathologies. Angiography is the diagnostic method of choice for further investigation. It allows precise localization of the bleeding site and simultaneous interventional therapy (embolization/coiling). The importance of further diagnostic modalities such as scintigraphy, capsule endoscopy, push-enteroscopy and double-balloon-enteroscopy is discussed.

Acute Disease↗

PubMed2002

[Inflammatory bowel diseases: diagnosis (including new procedures for small intestine examination)].

Medical history, clinical examination, general laboratory data and microbial stool examinations are basic diagnostics in inflammatory bowel diseases. Specific immunologic parameters can make classification easier in indefinite disease, their use is still in an experimental state. Ultrasound and endoscopic examinations have largely replaced conventional radiological procedures. For the experienced examiner, ultrasound allows assessment of small bowel and colon as well as other organs. Ileo-colonoscopy with biopsies remains the gold standard in the diagnosis of inflammatory bowel diseases. For small bowel examination, modern methods like push-enteroscopy, capsule endoscopy or the Hydro-MRI can be employed. At the moment, their usage is limited to specialized centers. Because of its broad availability small bowel follow through is still the standard in small bowel examination. After 8 years of colitis ulcerosa, ileo-colonoscopy with biopsy should be performed every year according to the guidelines. If these recommendations also apply to Crohn's disease is not sure yet.

Biomarkers↗

PubMed2006

[MALT-lymphoma].

Gastric lymphoma is most frequently an extranodal marginal zone-B-cell-lymphoma of mucosa-associated lymphoid tissue (MALT). The diagnosis is established by biopsy of the tumor. Computed-tomography, endosonography and recently capsule-endoscopy are used for staging. It is a relative new finding that MALT-lymphomas of the stomach are induced by Helicobacter pylori. A side-effect-poor breakthrough has been achieved by eradication of this bacterium with antibiotics. Refractory cases are amenable to radiotherapy, chemotherapy or surgical resection. The rarer aggressive lymphomas of the stomach are treated primarily by chemotherapy and radiotherapy. For both entities a further improvement may be achieved in ongoing prospective clinical trials by addition of the monoclonal antibody rituximab, which targets CD20 on lymphoma cells.

Biomarkers, Tumor↗

PubMed2004

Update on the etiology, pathogenesis and diagnosis of ulcerative colitis.

Evidence is accumulating that both genetic and environmental factors contribute to ulcerative colitis. The most consistent genetic associations have been shown for the MHC locus HLA Class II alleles, but the interleukin-1 family of genes and the multidrug resistance gene MDR1 have also been implicated as genetic susceptibility factors for the development of disease. In addition, there is a relationship between ulcerative colitis and bacterial flora, with an increased number of adherent Bacteroides spp. and Enterobacteriaceae spp. present in inflamed bowel segments. Conversely, cigarette smoking and appendectomy have both been shown to protect against the development of ulcerative colitis. Despite our improved understanding of the genetics and inflammatory mechanisms that underpin this disease, however, the etiology and pathogenesis of ulcerative colitis remain undefined. The diagnosis of ulcerative colitis is being aided by recent advances in diagnostic strategies, including the detection of fecal and serologic markers and the use of wireless capsule endoscopy, but, in the absence of a pathognomonic marker, the definition of this disease remains based on well-established clinical, endoscopic and histologic criteria. In particular, it is difficult to discriminate ulcerative colitis from other forms of colitis, including Crohn's disease, and there seems to be a growing overlap of pathophysiologic processes between ulcerative colitis and post-infectious irritable bowel syndrome. Patients who remain indeterminate between ulcerative colitis and Crohn's disease also continue to be a diagnostic challenge.

Biomarkers↗

PubMed2006

A patient with anemia of obscure origin: Crohn's disease in disguise.

BACKGROUND: A 65-year-old white Mediterranean male with a 10-year history of intermittent anemia, who was otherwise completely asymptomatic, was referred to our hospital in March 2004. He had a medical history of beta thalassemia and fecal occult blood tests had occasionally been positive. INVESTIGATIONS: Fecal occult blood test, laboratory investigations, esophagogastroduodenoscopy, colonoscopy with retrograde ileoscopy, mesenteric angiography, small-bowel series, CT scan of the abdomen and pelvis, Meckel's scan, and capsule endoscopy. Laparoscopic surgery followed by macroscopic and microscopic histopathologic examination of samples obtained during the procedure. DIAGNOSIS: Crohn's disease of the small bowel. MANAGEMENT: Laparoscopic segmental small-bowel resection with end-to-end anastomosis. Postsurgical treatment with Pentasa 4 g a day.

Aged↗

PubMed2002

Push enteroscopy for recurrent gastrointestinal hemorrhage due to jejunal anastomotic varices: a case report and review of the literature.

Small-bowel anastomotic and adhesion-related varices can form within adhesions in the setting of mesenteric venous hypertension, arising from either mesenteric venous obstruction or portal hypertension. In evaluating gastrointestinal bleeding in patients who have had previous abdominal surgery and mesenteric venous hypertension, small-bowel anastomotic varices and adhesion-related varices should be considered. For patients with recurrent, severe melena or hematochezia, we recommend that the initial diagnostic work-up should include push enteroscopy in patients with previous small-bowel surgery. Retrograde ileoscopy should also be considered these patients to look for distal small-bowel varices. Potentially, such small-bowel varices can be identified by wireless capsule endoscopy. We report a case of recurrent gastrointestinal bleeding caused by jejunal anastomotic varices which were secondary to superior mesenteric vein occlusion following an abdominal gunshot wound. Although the treatment of segmental varices has been surgical resection, for patients with overt systemic portal hypertension, a transjugular intrahepatic portal-systemic shunt or a decompressive shunting procedure are recommended.

Adult↗

PubMed2004

Ulcers and gastritis.

Significant advances continue to be made in the area of gastritis and ulcer disease. Studies to identify the most appropriate use of capsule endoscopy have now confirmed that it is superior to other methods for identifying small-bowel mucosal pathology and sites of obscure gastrointestinal bleeding. It has increasingly been recognized that the complications of ulcer disease are secondary to the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and to interactions between NSAIDs and Helicobacter pylori. Effective prophylaxis for NSAID ulcers in H. pylori-negative individuals continues to be a challenge, as it has become clear that conclusions from studies focusing on "endoscopic ulcers" in patients whose H. pylori status was unknown provided a false sense of security. The concept of multifocal atrophic gastritis has been challenged. The precursor lesion to gastric cancer now appears to be a sheet of pseudopyloric metaplasia advancing into the gastric body with islands of intestinal metaplasia embedded within it. Multifactorial models such as those proposed for understanding periodontal disease, including the organism, environmental factors, and host factors, appear particularly applicable to understanding the pathogenesis of H. pylori-associated gastric cancer.

Endoscopy, Gastrointestinal↗

PubMed2004

Inflammatory bowel disease: what is new?

This article reviews a selection of 50 papers on inflammatory bowel disease published between April 2002 and August 2003. The new information and progress summarized here includes: the role of bacteria, their interaction with CARD15/NOD2 gene products and the modulating effects of probiotics; new imaging techniques, such as wireless capsule endoscopy and chromoendoscopy for detecting dysplasia, and fecal markers. It has not been possible to review every aspect of treatment, and the focus here is on factors capable of predicting the efficacy and tolerance of infliximab and new treatments, including natalizumab, thalidomide, cyclophosphamide and 6-thioguanine.

Antibodies, Monoclonal↗

PubMed2005

The rate of lesions found within reach of esophagogastroduodenoscopy during push enteroscopy depends on the type of obscure gastrointestinal bleeding.

BACKGROUND AND STUDY AIMS: Many lesions found during push enteroscopy to evaluate obscure gastrointestinal bleeding are within the reach of standard endoscopes. The aim of this study was to determine whether the rate of proximal lesions varies in relation to the type of obscure bleeding that is present. PATIENTS AND METHODS: A retrospective review of consecutive push enteroscopies carried out for obscure gastrointestinal bleeding between July 1996 and July 2000 was conducted. The patients were categorized into three groups: those with recurrent obscure/overt gastrointestinal bleeding; those with persistent obscure/overt gastrointestinal bleeding; and those with obscure/occult gastrointestinal bleeding. RESULTS: A total of 63 patients (24 men, 39 women; mean age 69.8) were included. Push enteroscopy examinations were conducted for recurrent obscure/overt bleeding in 32 patients; for persistent obscure/overt bleeding in 12 patients; and for obscure/occult bleeding in 19 patients. The overall diagnostic yield of push enteroscopy was 47 % (15 of 32) in the group with recurrent obscure/overt bleeding; 66 % (eight of 12) in the group with persistent obscure/overt bleeding; and 63 % (12 of 19) in the group with obscure/occult bleeding. However, when lesions within the reach of standard esophagogastroduodenoscopy (EGD) were excluded, the yield of push enteroscopy was slightly higher in the group with recurrent obscure/overt bleeding (41 %) than in the groups with persistent obscure/overt bleeding (33 %) and obscure/occult bleeding (26 %). There were fewer lesions within the reach of EGD in the group with recurrent obscure/overt bleeding than in the groups with persistent obscure/overt bleeding (6 % vs. 33 %; P < 0.05) or obscure/occult bleeding (6 % vs. 37 %; P < 0.05). CONCLUSIONS: Patients undergoing push enteroscopy for recurrent obscure/overt bleeding were significantly less likely to have lesions within the reach of EGD than patients with persistent obscure/overt bleeding or obscure/occult bleeding. Patients in the latter two groups would be able to undergo a repeat EGD examination before more intense evaluation with push enteroscopy or capsule endoscopy.

Aged↗

PubMed2006

Cavernous transformation of the portal vein complicating pregnancy.

BACKGROUND: Cavernous transformation of the portal vein, associated with varices and thrombocytopenia, rarely complicates pregnancy. CASE: A 20-year-old primigravida with cavernous transformation of the portal vein underwent wireless video esophageal capsule endoscopy at 28 weeks of gestation, which ruled out esophageal and gastric varices and the need for prophylactic sclerotherapy. Magnetic resonance angiography at 32 weeks of gestation showed no abdominal wall varices or abnormally dilated lumbar or extradural veins, which ensured a safe surgical approach for cesarean and preserved the patient's ability to receive regional anesthesia. CONCLUSION: New noninvasive imaging modalities aided evaluation and management of the gravida with cavernous transformation of the portal vein.

Adult↗

PubMed2005

Crohn's jejunoileitis: the pediatrician's perspective on diagnosis and management.

Although uncommon, diffuse jejunoilietis is one of the most difficult areas in Crohn's disease (CD) to treat. Although the exact frequency is unknown, most gastroenterologists believe that its prevalence has been underestimated and that it may have an increased incidence among children and young adolescents. The clinical importance of this clinical disease phenotype is the impact diffuse small bowel disease is expected to have on a child's growth and development. Moreover, patients with jejunoileitis are more likely to experience complications, including fistulization, and most commonly, intestinal obstruction. The associated morbidity and frequent need for surgical intervention renders these patients at risk for intestinal insufficiency. Although stricturoplasty has reduced the incidence of short bowel syndrome, most patients with proximal small bowel CD still require repeated surgical intervention. Jejunoileitis represents a distinct clinical phenotype within the heterogenous family of disease phenotypes considered as CD. Whether a specific genotype will be found to associate with jejunoileitis remains to be determined. Through the development of novel diagnostic techniques, including gadolinium enhanced magnetic resonance imaging (GMRI), enteroscopy, and capsule endoscopy, the mean age at diagnosis is expected to decrease. Coupled with an increase in clinical suspicion, early diagnosis may allow physicians to consider implementing aggressive immunomodulatory therapy. Future studies are needed to determine if the early detection and use of immune modulators in patients with proximal small bowel disease will improve overall quality of life and decrease the risk of nutritional and surgical comorbidity.

Adolescent↗

PubMed2006

Intestinal polyposis syndromes: progress in understanding and treatment.

PURPOSE OF REVIEW: Dramatic advances in the understanding of the genetic basis for inherited diseases and in diagnosis and treatment are particularly applicable to intestinal polyposis. Recent contributions have impacted our understanding of the molecular basis for the disease and improved our ability to treat them. RECENT FINDINGS: Insights into the genetic basis of the spectrum of disease and refinement of genetic screening, diagnostic tests, and surgical management of intestinal polyposis and extraintestinal manifestations are reviewed. SUMMARY: Our understanding of the genetic basis for the intestinal polyposis syndromes remains incomplete, but recent studies have contributed to filling in significant gaps in our knowledge. Specific genetic alterations have been identified in the majority of the 30% of patients with familial adenomatous polyposis that do not test positive for mutations in the APC gene with routine testing. A novel gene ENG has been identified in a subgroup of patients with Peutz-Jegher's syndrome and a hypothesis has been proposed to explain the pathogenesis of the mucosal defects. Technological advancements in diagnosis and treatment include the use of capsule endoscopy for screening and the minimally invasive approach to total colectomy with ileoanal pullthrough. Treatment of desmoid tumors remains a challenge, but new chemotherapy regimens show some promise in treating this rare, but devastating, extraintestinal manifestation.

Child↗

PubMed2006

Meckel's scan: pitfall in patients with active small bowel bleeding.

Potential for a false-positive Meckel's scan is highlighted in this patient with intermittent, low-volume small bowel bleeding. Meckel's scan showed late appearance of focal activity mimicking a positive diverticulum finding. This was secondary to extravasated tracer during a coincidental bleeding as shown by a Tc-99m tagged red blood cell scan obtained 2 days earlier. Inaccurate diagnosis of Meckel diverticulum was avoided by: 1) noticing the late appearance in relationship to the gastric uptake, and 2) showing motility of the focus on delayed dynamic imaging that confirmed transit of extravasated tracer along the small bowel with peristalsis. Subsequent capsule endoscopy showed a bleeding ulcer in the ileum.

Diagnostic Errors↗

PubMed2003

Performance of Given suspected blood indicator.

OBJECTIVES: Given Imaging (Yoqneam, Israel) has developed a suspected blood indicator (SBI) function for its wireless capsule endoscopy (WCE) software. The SBI detects blood and marks appropriate images for interrogation. The sensitivity and accuracy of SBI and its role in examining WCE studies is unknown. Our aim was to evaluate the accuracy of this new software in detecting small bowel lesions. METHODS: WCE reports of all patients referred for WCE in October and November, 2002, were reviewed. The images from each patient were reviewed by experienced gastroenterologists at 15 frames/s. The findings detected by gastroenterologists were compared to those recognized by SBI. Arteriovenous malformations (AVMs), ulcers, erosions, and sites of active bleeding were considered significant lesions. RESULTS: A total of 24 patients (16 women and eight men, mean age 59 yr) were studied during this period. The indications for the study were iron deficiency anemia in 18 patients and abdominal pain in six patients. A total of 109 lesions were identified by gastroenterologists (47 AVMs, 18 active bleeding ulcers, 18 ulcers without bleeding, and 26 erosions). Active bleeding seen by gastroenterologists was secondary to AVMs (five cases), jejunal ulcers (11 cases, all in the same patient), and gastric ulcers (two cases). A total of 31 potential areas of blood were identified by SBI. When compared to those findings recognized by gastroenterologists, 28 lesions were correctly identified (six AVMs, 13 active bleeding ulcers, (three AVMs and 10 jejunal ulcers), seven nonbleeding ulcers, and two nonbleeding erosions. The overall sensitivity, positive predictive value, and accuracy of SBI to detect significant small bowel lesions were 25.7%, 90%, and 34.8%, respectively. If only actively bleeding lesions in the small bowel were considered, SBI had sensitivity, positive predictive value, and accuracy of 81.2%, 81.3%, and 83.3%, respectively. CONCLUSIONS: SBI has good sensitivity and positive predictive value for actively bleeding lesions in the small bowel. Complete review of the study by the physician is still needed. SBI should be considered as a complementary and rapid screening tool for gastroenterologists to identify actively bleeding lesions.

Chi-Square Distribution↗

PubMed2006

Push-and-pull enteroscopy using the double-balloon technique (double-balloon enteroscopy) for the diagnosis of Meckel's diverticulum in adult patients with GI bleeding of obscure origin.

BACKGROUND: Meckel's diverticulum (MD) occurs in 2-3% of the population. Although the clinical, histopathologic, and radiologic features of the complications of MD are well known, the diagnosis may be difficult before surgery. CASE REPORT: Three patients (age 22-34 yr, two women) presenting with gastrointestinal (GI) bleeding of obscure origin underwent multiple endoscopic and radiologic tests including capsule endoscopy and Tc-99m pertechnetate scintigraphy before push-and-pull enteroscopy using a double-balloon technique (double-balloon enteroscopy). Double-balloon enteroscopy was performed in all three patients using oral and anal approaches to evaluate the entire intestine. In one case, MD was detected using the oral route; the diagnosis was confirmed using the anal approach. In two patients, the lumen of MD was disclosed using the anal route. No procedure-related complications occurred. Push-and-pull enteroscopy was the only nonsurgical procedure that provided a precise diagnosis. All patients underwent surgical resection of the diverticulum. In one case, ectopic gastric tissue was found histologically. No further bleeding occurred during follow-up (6-9 months). CONCLUSIONS: Keeping the low sensitivity of Tc-99m scintigraphy in the adult population in mind, double-balloon enteroscopy might be the modality of choice in young adult patients with acute recurrent GI bleeding of obscure origin and a suspected diagnosis of MD.

Adult↗