A Prospective Comparison of Capsule Endoscopy, Enteroclysis and Enteroscopy in Peutz-Jeghers Syndrome

Abstract

Background: Peutz-Jeghers syndrome (PJS) is characterized by the presence of hamartomatous polyps throughout the gastrointestinal tract, most frequently in the small intestine. Management centres on the prevention of gastrointestinal complications arising from small bowel polyposis. Small bowel radiography is recommended to reduce the risk of complications. Capsule endoscopy is a promising technique for endoscopic surveillance of small bowel polyposis. Aims: To compare polyp detection rates in patients with known PJS, using capsule endoscopy (CE), small bowel enteroclysis (SBE) and push enteroscopy (PE). Methods: 14 patients with established PJS were enrolled prospectively and 11 (4M7F) have completed evaluation (mean age/range M27.2/17-39, F30.6/17-57). After initial clinical evaluation to confirm the diagnosis, patients were evaluated by blinded investigators. All patients underwent SBE and CE before proceeding to PE when possible. SBE was performed by an expert gastrointestinal radiologist, using naso-jejunal intubation and double contrast technique (barium, methylcellulose and water). PE was performed by an experienced endoscopist using an Olympus SIF140 250 cm enteroscope. Polyps were deemed to be clinically significant when ≥1 cm (as measured at fluoroscopy, or at PE using an open biopsy forcep technique, or when occupying the majority of the lumen on CE). Patients were referred for surgery where clinically appropriate. Results: 3 patients (27%) did not tolerate nasojejunal intubation for SBE, and the procedure was performed as a barium meal with follow through. The difference between the mean number of polyps detected by SBE (0.54, range 0-1) and CE (2.63, range 0-10) approached statistical significance (p = 0.06). PE was undertaken in 8 patients (4M4F) and the mean number of polyps found was 2.42. Conclusions: These data suggest that capsule endoscopy should be the first-line investigation of the small bowel in PJS, rather than small bowel enteroclysis. In comparison with CE, SBE appears to have poor sensitivity in detecting clinically significant small bowel polyps. PE confirmed the presence of proximal polyps found on CE. CE may have underestimated the number of large polyps clustered in the proximal small bowel (as is common in PJS). CE did detect a number of distal polyps not identified on PE. Capsule endoscopy findings can be used to direct subsequent management (surgery or PE) depending on the location of the polyps. Background: Peutz-Jeghers syndrome (PJS) is characterized by the presence of hamartomatous polyps throughout the gastrointestinal tract, most frequently in the small intestine. Management centres on the prevention of gastrointestinal complications arising from small bowel polyposis. Small bowel radiography is recommended to reduce the risk of complications. Capsule endoscopy is a promising technique for endoscopic surveillance of small bowel polyposis. Aims: To compare polyp detection rates in patients with known PJS, using capsule endoscopy (CE), small bowel enteroclysis (SBE) and push enteroscopy (PE). Methods: 14 patients with established PJS were enrolled prospectively and 11 (4M7F) have completed evaluation (mean age/range M27.2/17-39, F30.6/17-57). After initial clinical evaluation to confirm the diagnosis, patients were evaluated by blinded investigators. All patients underwent SBE and CE before proceeding to PE when possible. SBE was performed by an expert gastrointestinal radiologist, using naso-jejunal intubation and double contrast technique (barium, methylcellulose and water). PE was performed by an experienced endoscopist using an Olympus SIF140 250 cm enteroscope. Polyps were deemed to be clinically significant when ≥1 cm (as measured at fluoroscopy, or at PE using an open biopsy forcep technique, or when occupying the majority of the lumen on CE). Patients were referred for surgery where clinically appropriate. Results: 3 patients (27%) did not tolerate nasojejunal intubation for SBE, and the procedure was performed as a barium meal with follow through. The difference between the mean number of polyps detected by SBE (0.54, range 0-1) and CE (2.63, range 0-10) approached statistical significance (p = 0.06). PE was undertaken in 8 patients (4M4F) and the mean number of polyps found was 2.42. Conclusions: These data suggest that capsule endoscopy should be the first-line investigation of the small bowel in PJS, rather than small bowel enteroclysis. In comparison with CE, SBE appears to have poor sensitivity in detecting clinically significant small bowel polyps. PE confirmed the presence of proximal polyps found on CE. CE may have underestimated the number of large polyps clustered in the proximal small bowel (as is common in PJS). CE did detect a number of distal polyps not identified on PE. Capsule endoscopy findings can be used to direct subsequent management (surgery or PE) depending on the location of the polyps.