Evaluation Of Small Bowel Diseases Research Articles

Diagnostic utility of computer tomographic enterography for patients presenting with unexplained gastrointestinal symptoms.

Computer tomographic enterography (CTE) is gaining approval for evaluation of small bowel diseases. However, the diagnostic yields of CTE for diseases other than Crohn's disease have not yet been well elucidated. The aim of the present study was to determine the diagnostic utility of CTE and to ascertain the clinical factors predictive of the positive diagnostic rate in patients with unexplained gastrointestinal symptoms or signs. The clinical and radiological data of 193 patients with unexplained gastrointestinal symptoms that had a CTE examination at Severance Hospital between May 2007 and April 2010 were retrospectively analyzed. CTE revealed positive findings that explained the symptoms in 51 of the 193 patients (diagnostic yield 26.4%). Positive findings of diagnosis included cancer (12 patients), Crohn's disease (10), intestinal stricture/obstruction (9), small bowel bleeding (7), colitis (6), intestinal Behcet's disease (4), intestinal tuberculosis (2) and intestinal fistula (1). According to univariate analysis, the positive findings of CTE were significantly associated with higher segmentated neutrophil count (p<0.001), higher erythrocyte sedimentation rate (ESR) (p=0.003), higher C-reactive protein (CRP) level (p=0.008) and lower serum albumin level (p=0.037). Multivariate analysis indicated that elevated CRP level was a significant risk factor for the positive findings of CTE (odds ratio 1.950; 95% CI (1.165-3.265), p=0.011). The results of this study suggest that CTE could be helpful in patients suffering from unexplained gastrointestinal symptoms that cannot be explained by established examinations, especially those with elevated C-reactive protein levels.

A ressonância magnética na doença de crohn do intestino delgado

Crohn's disease (CD) is a chronic relapsing inflammatory disease of the gastrointestinal tract, which mostly affects young patients. Imaging techniques form a very important part for the evaluation of CD and for monitoring disease progression or response to therapy. Currently, imaging of CD is increasingly being performed by cross-sectional modalities, i.e. multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI), since these techniques allow for simultaneous visualization of luminal, mural and extraintestinal disease extension. MR enterography has the potential to safely and noninvasively accomplish the imaging needs of patients with Crohn disease without exposing them to ionizing radiation. The new imaging paradigm should contemplate patient safety as a very important aspect when assessing the role of an imaging modality in comparison with others. For this reason, MRI may be the preferred modality for evaluation of small bowel disease, especially in young patients in the setting of CD, considering that the majority will undergo frequent repeat studies. Also, the information on disease activity is not matched by any other imaging method. In this review article, the authors discuss the essential aspects of MR evaluation of CD, including protocol and imaging findings, also referring the advantages over other radiological studies, concerning safety, accuracy and potential importance for therapeutic approach.

Safety of Capsule Endoscopy Using Human Body Communication in Patients with Cardiac Devices

The MiroCam (IntroMedic, Ltd., Seoul, Korea) is a small-bowel capsule endoscope that uses human body communication to transmit data. The potential interactions between cardiac devices and the capsule endoscope are causes for concern, but no data are available for this matter. This clinical study was designed to evaluate the potential influence of the MiroCam capsules on cardiac devices. Patients with cardiac pacemakers or implantable cardiac defibrillators referred for evaluation of small bowel disease were prospectively enrolled in this study. Before capsule endoscopy, a cardiologist checked baseline electrocardiograms and functions of the cardiac devices. Cardiac rhythms were continuously monitored by 24-h telemetry during capsule endoscopy in the hospital. After completion of procedures, functions of the cardiac devices were checked again for interference. Images from the capsule endoscopy were reviewed and analyzed for technical problems. Six patients, three with pacemakers and three with implantable cardiac defibrillators, were included in the study. We identified no disturbances in the cardiac devices and no arrhythmias detected on telemetry monitoring during capsule endoscopy. No significant changes in the programmed parameters of the cardiac devices were noted after capsule endoscopy. There were no imaging disturbances from the cardiac devices on capsule endoscopy. Capsule endoscopy using human body communication to transmit data was safely performed in patients with cardiac pacemakers or implantable cardiac defibrillators. Images from the capsule endoscopy were not affected by cardiac devices. A further large-scale study is required to confirm the safety of capsule endoscopy with various types of cardiac devices.

Small bowel MRI in adult patients: not just Crohn’s disease—a tutorial

ObjectivesTo provide an overview of less well-known small bowel and mesenteric diseases found at small bowel magnetic resonance (MR) enterography/enteroclysis and to review the imaging findings. MR enterography and enteroclysis are important techniques for evaluation of small bowel diseases. In most centres these techniques are primarily used in Crohn’s disease, and most radiologists are familiar with these MRI findings. However, the knowledge of findings in other diseases is often sparse, including diseases that may cause similar clinical symptoms to those of Crohn’s disease.MethodsWe present a spectrum of less common and less well-known bowel and mesenteric diseases (e.g. internal hernia, intussusception, neuroendocrine tumour) from our small bowel MR database of over 2,000 cases.ResultsThese diseases can be found in patients referred for bowel obstruction, abdominal pain or rectal blood loss. Further, in patients with (or suspected to have) Crohn’s disease, some of these diseases (e.g. neuroendocrine tumour, familial Mediterranean fever) may mislead radiologists to erroneously diagnose active Crohn’s disease.ConclusionRadiologists should be familiar with diseases affecting the small bowel other than Crohn’s disease, including diseases that may mimic Crohn’s disease.

CT-Enterography May Identify Small Bowel Tumors Not Detected by Capsule Endoscopy: Eight Years Experience at Mayo Clinic Rochester

Capsule endoscopy (CE) is widely accepted as the preferred diagnostic test in the evaluation of small bowel diseases. However, small bowel tumors (SBT) are sometimes missed by CE. Preliminary studies suggest that CT-enterography (CTE) may play a role in detecting SBT. The purpose of this study was to compare the performance of CE and CTE in detecting SBT METHODS: This was a single center, retrospective study. Patients treated at the Mayo Clinic Rochester between January 2000 and December 2008 with a discharge diagnosis of SBT and negative initial esophagogastroduodenoscopy (EGD) and colonoscopy were identified through a search of the electronic medical records. Among 103 identified patients, 41 had undergone CE, CTE or both, and comprised our study group. The exact binomial sensitivity of CE and CTE in detecting SBT was calculated. Demographic characteristics, clinical presentation, results of diagnostic tests, and tumor characteristics were recorded for each patient. CTE and CE detected 38/41 (sensitivity 92.7%; 95% CI 80.1-98.5) and 8/27 (sensitivity 29.6%; 95% CI 13.8-50.2) of the SBT identified at Mayo Clinic Rochester, respectively. Seventeen patients had both CTE and CE. In this subgroup of patients, CTE detected SBT in 16/17 (sensitivity 94.1; 95% CI 72.7-99.9) and CE in 6/17 (sensitivity 35.3%; 95% CI 13.3-59). The matched paired difference in the sensitivity of two techniques in detecting SBT was statistically significant (P=0.004). CTE may identify SBT not diagnosed by CE.

Comparison of neutral and positive enteral contrast media for MDCT enteroclysis

To compare neutral and positive enteral contrast media for MDCT enteroclysis (MDCTE) in various small bowel diseases. 40 patients with suspicion of small bowel diseases were divided randomly into two equal groups. In one group, water was used as neutral enteral contrast and in other group, 2% water soluble iodinated contrast was used as positive enteral contrast. All MDCTE were done on a 16-slice multidetector row CT unit. The findings of MDCTE were compared with the standards of reference. There were 12 cases of abdominal tuberculosis (30%), 5 cases of bowel masses (12%), 4 cases of Crohn's disease (10%), 3 cases of small bowel adhesions (7%), 2 cases of midgut volvulus (5%), 2 cases of segmental enteritis (5%) and 12 of all cases (30%) were normal. There was no statistically significant difference between neutral and positive enteral contrast with regards to bowel distention, contrast reflux and evaluation of duodenum. Abnormal bowel wall enhancement was appreciated only with use of neutral enteral contrast (n=12). Evaluation of ileocaecal junction was possible in all 20 patients (100%) with positive enteral contrast but in only 17 patients (85%) with neutral enteral contrast. Overall sensitivity and specificity of MDCTE with use of neutral contrast medium (100 and 88% respectively) was greater for evaluation of small bowel diseases, when compared to MDCTE using positive enteral contrast medium (92.8 and 83.3% respectively). Water is a good enteral contrast medium for MDCT enteroclysis examination and allows better evaluation of abnormal bowel wall enhancement. Ileocaecal junction evaluation is better with positive enteral contrast medium.

Gastroenterologic and Radiologic Approach to Obscure Gastrointestinal Bleeding: How, Why, and When?

Gastrointestinal (GI) bleeding is a common clinical condition that is increasingly seen in an aging population and frequently requires hospitalization and intervention, with significant morbidity and mortality. Obscure GI bleeding (OGIB) is defined as loss of blood with no source identified after upper endoscopy and colonoscopy. Whether an obscure site of bleeding is clinically evident or silent, it constitutes a diagnostic and therapeutic challenge for the clinician. Gastroenterology and radiology provide the essential diagnostic tools used to evaluate suspected OGIB, each with its strengths and weaknesses. Small bowel series and conventional enteroclysis have a limited role in OGIB. Computed tomographic (CT) enterography and CT enteroclysis are noninvasive techniques with promising results in evaluation of small bowel disease and silent OGIB. CT angiography is a useful triaging tool for diagnosing or excluding active GI hemorrhage, localizing the site of bleeding, and guiding subsequent treatment. Tagged red blood cell scanning is the most sensitive technique for detection of active GI bleeding and allows imaging over a prolonged period, making it useful for detecting intermittent bleeding. Capsule endoscopy has emerged as an important tool for investigating OGIB, but it may soon have competition from double-balloon enteroscopy, a diagnostic technique that can also facilitate therapy.

CT-Enterography is More Sensitive Than Capsule Endoscopy in the Diagnosis of Endoscopy-Negative Small Bowel Tumors -The Mayo Clinic Rochester Experience

Purpose: There is no standard imaging tool to evaluate patients with suspected small bowel disease who have had initial negative upper and lower gastrointestinal endoscopies. Conventional imaging techniques have low sensitivity. Capsule endoscopy (CE) is being widely accepted as the first line diagnostic procedure to image the small bowel in these patients. Small bowel tumors, however, are frequently submucosal and may be difficult to see on capsule endoscopy. Recently, we have found CT-Enterography (CTE) to be very useful in the evaluation of small bowel disease. The purpose of this study was to compare the sensitivity of CE and CTE in the detection of small bowel tumors in patients with negative initial EGD and colonoscopy. Methods: Medical records of patients with a dismissal diagnosis of a small bowel tumor were retrieved and reviewed using the electronic medical records of the Mayo Clinic Rochester from January 2000 to December 2008. A total of 103 patients with newly diagnosed endoscopy (EGD and colonoscopy) negative small bowel tumors were identified. Of these, 41 patients had undergone CE, CTE, or both. The exact binomial sensitivity of CE and CTE in detecting small bowel tumors was compared. Results: CE was performed in 27 patients, of whom small bowel tumors were detected in 8 (sensitivity 29.6%: 95% CI 13.8, 50.2). CT-Enterography was performed in 41 patients, of whom small bowel tumors were detected in 38 (sensitivity 92.7%: 95% CI 80.1, 98.5). The tumors detected and not detected with each method are shown in Table 1. Seventeen patients underwent both CTE and CE; CTE detected small bowel tumors in 16 (sensitivity 94.1: 95% CI 71.3, 99.9) and CE in 6 patients (sensitivity 35.3%: 95% CI 14.2, 61.7); 3 of the 4 patients with positive capsule endoscopy and in all of the 13 patients with negative capsule endoscopy subsequently demonstrated small bowel tumors on CTE performed within a median interval of 8 days (range 3 days to 25 days) after CE (p=0.24). This head to head comparison is shown in Table 2.Table 1: Small bowel tumors detected and not detected by capsule endoscopy and or CT-enterographyTable 2: Head to head comparison in patients who had both Capsule Endoscopy and CT- EnterographyConclusion: In our initial experience, CTE (sensitivity 92.7%) is superior to CE (sensitivity 29.6%) in detecting small bowel tumors. Head to head comparison of the two methods in patients who had both studies shows a strong trend favoring CTE but did not reach statistical significance. A study with larger number of patient is needed to further assess this comparison.

Capsule endoscopy and balloon-assisted endoscopy: competing or complementary technologies in the evaluation of small bowel disease?

Capsule endoscopy and balloon-assisted endoscopy have revolutionized our ability to evaluate the small bowel. In this review, we will address the question 'capsule endoscopy and balloon-assisted endoscopy: competing or complementary technologies?' Capsule endoscopy will effect clinical management in about 50% of cases with obscure gastrointestinal bleeding with complete small bowel endoscopy performed in over 80% of cases. Currently, most data on balloon-assisted endoscopy involve double balloon endoscopy (DBE), which has a diagnostic yield of 60%. Complete small bowel endoscopy with bidirectional endoscopy is possible in 50% of cases. Meta-analyses have suggested capsule endoscopy and DBE to have fairly similar diagnostic yields and to be complementary. Capsule endoscopy-directed DBE is a useful strategy. Lesions found in the first 75% of capsule endoscopy transit time have a high probability of being found on oral DBE. Endoscopic treatment and/or biopsy of capsule endoscopy lesions can be routinely obtained at DBE. A negative capsule endoscopy study without persistent bleeding has a good prognosis and can often obviate the need for DBE, a currently limited resource. Capsule endoscopy and balloon-assisted endoscopy are complementary procedures. Capsule endoscopy should be done first to direct the approach by balloon-assisted endoscopy. If the capsule endoscopy is negative, balloon-assisted endoscopy should be performed only in patients with a high suspicion of small bowel disease.

Utility of Double Balloon Endoscopy for the Diagnosis and Treatment of Stomach and Small Intestine Disorders in Patients with Gastric Bypass

The double balloon endoscope was initially devised for the endoscopic evaluation of small bowel diseases. However, the indications of its use have increased for patients with altered gastrointestinal anatomy after surgery because of its controlled capacity to reach the bypassed organs. One of these situations includes patients with Roux-en-Y gastric bypass, one of the most common surgical techniques performed for morbid obesity. In such patients, the bypassed stomach is inaccessible by conventional upper endoscopy, and the endoscopic and pathological changes of the bypassed stomach are unknown in a long-term period. Aside from common therapeutic procedures like hemostasis and polypectomy, the development of the endoscopic accessories allows the performance of other procedures, such as percutaneous endoscopic gastrostomy and endoscopic retrograde cholangiopancreatography, in such patients.

Enteroclysis in older children and teenagers

Enteroclysis (EC) has been widely and successfully used for evaluation of the small bowel in adults for about 30 years. However, despite recently improved intubation and examination techniques, in many paediatric radiology centres it is still not the preferred conventional barium study for the evaluation of small bowel pathology in children. To share our 10 years of experience and review the feasibility of EC in 83 older children and teenagers, in terms of both technique and pathological findings. Between 1996 and 2006, EC was performed by the standard technique described by Herlinger to 83 children between 7 and 18 years of age. The indication for the study was jointly decided by the paediatric radiologist and the clinician. None of the examinations was converted to follow-through studies because of patient refusal or technical failure. Morphological changes, mucosal abnormalities, luminal abnormalities, perienteric structures, the location of the disease, indirect findings regarding the bowel wall and functional information were evaluated. All the children tolerated the procedure without difficulty. Out of 83 patients, 63 had abnormal findings. The spectrum of diagnoses were Crohn disease (n = 23), nonspecific enteritis (n = 10), malabsorption (n = 8), intestinal tuberculosis (n = 6), intestinal lymphoma (n = 5), Peutz-Jegher syndrome (n = 3), adhesions (n = 2), Behçet disease (n = 2), back-wash ileitis due to ulcerative colitis (n = 2), common-variable immune deficiency (n = 1) and lymphangiectasis (n = 1). EC can easily be performed in children over 7 years of age and when performed using a correct technique it shows high diagnostic performance without any complications in the evaluation of small bowel diseases in older children and teenagers.

Wireless Capsule Endoscopy in Inflammatory Bowel Disease: State of the Art and Image of the Future

Wireless Capsule Endoscopy in Inflammatory Bowel Disease: State of the Art and Image of the Future

Comparison of Double Balloon Enteroscopy and Small Bowel Series in the Evaluation of Small Bowel Lesion

Background/Aims: The role of double balloon enteroscopy (DBE) is still evolving. The aim of this study was to compare the diagnostic yield of DBE with that of small bowel series (SBS). Methods: We enrolled patients with suspected small bowel disease consecutively, and performed both DBE and SBS in all patients. Results: Eighteen patients (M:F=12:6, 14-82 years) were included. Indications for small bowel evaluation were obscure gastrointestinal bleeding (10), abdominal pain (5), diarrhea (2) and abnormal CT finding (1). Of 10 obscure gastrointestinal bleeding patients, 6 showed the same findings in both studies. However, 4 showed negative findings in SBS while DBE detected erosions or ulcerations. Of 5 abdominal pain patients, 3 showed the same results in both studies. However, 2 demonstrated different results. One was suspected of early Crohn’s disease in SBS, but proved to be normal in DBE, and the other was suspected of malignancy in SBS but was suspected of benign ulcers in DBE. Of 2 chronic diarrhea patients, one was diagnosed as Crohn’s disease in both studies. The other was suspected of tuberculosis in SBS but diagnosed as lymphangiectasia by DBE with biopsy. One patient with jejunal wall thickening in CT proved to be normal in both DBE and SBS. There were no serious complications associated with DBE and SBS. Conclusions: DBE is better than SBS in terms of diagnostic accuracy. DBE may become an important method for the evaluation of small bowel diseases. (Korean J Gastroenterol 2006;48: 25-31) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

Capsule Endoscopy in a Series of Preschool Age Children with Obscure Gastrointestinal Bleeding

Background: Capsule endoscopy (CE) has been demonstrated to be safe and well tolerated when used in the assessment of pediatric gastrointestinal disease. Current data on CE in children has been limited to information from studies on children over the age of 9 years. It has been suggested that its use in younger children may need to be restricted due to the potential for retention of the capsule due to an inability to pass through a smaller lumen of the pediatric gastrointestinal tract. Methods/Results: Three children underwent CE, ages 2.1, 2.5 and 4 years, with obscure GI bleeding. Two patients had biliary atresia and had undergone a Kasai portoenterostomy with creation of a Roux en Y loop in infancy. The other child had a history of dyskeratosis congenita and had a bone marrow transplant. All patients had undergone standard workup including EGD and colonoscopy that did not reveal the source of the bleeding. In each patient, the PillCam™ SB (Given Imaging) capsule was placed with the aid of a gastroscope under general anesthesia without complications. In two patients, a polyp retrieval device mounted at the tip of the gastroscope was used to place the capsule in the duodenum. The entire small bowel was visualized in two patients. One procedure was incomplete with the capsule located in the jejunum at the end of study period. No signs of bowel obstruction presented at any point during the study. In all patients, the capsule was identified in the patient's stool within 24 hours after initiating the procedure. Small intestinal lesions consistent with a source for GI bleeding were found in all patients. These included portal hypertensive enteropathy in the first patient, single jejunal hemangioma in the second, and jejunal angiodysplasia in the third patient. All the CE procedures were tolerated well without any adverse events. Conclusion: This is the first reported series of patients in this young age group to have undergone capsule endoscopy. The capsule passed readily through the GI tract in these children and provided valuable clinical data. This experience suggests that CE may be a safe and effective diagnostic tool in the evaluation of small bowel disease in preschool age children. Further study is warranted to validate the utility of CE in this population.

A prospective comparison of enteroclysis and capsule endoscopy in the diagnosis of obscure gastrointestinal bleeding

Purpose: Enteroclysis is considered the gold standard for evaluation of small bowel diseases. Small bowel series is preferred because of its simplicity and lack of patient (pt) discomfort. Recently, capsule endoscopy (CE) was shown to be superior to small bowel radiography for evaluation of small bowel diseases. (Gastroenterol 2002; 123; 999–1005) This study was undertaken to prospectively study the diagnostic yield of enteroclysis compared with CE in pts with obscure gastrointestinal bleeding.

The importance of indication in the diagnostic value of push enteroscopy.

Small-bowel enteroscopy (SBE) is frequently used to examine patients suspected of small-bowel disease. Unfortunately, the diagnostic yield varies widely, from 13 % to 78 % of cases. This disparity may be in part attributable to the vast array of indications for the use of the procedure. The purpose of this study was to examine the diagnostic yield of small-bowel enteroscopy for various indications. This is a retrospective cohort study of all patients who underwent SBE over a 5-year period, from 1995 to 1999. The indications were grouped into in-patient gastrointestinal blood loss (46% of the patient population), outpatient gastrointestinal blood loss (33 %), abnormal radiographic study (7%), iron-deficiency anemia (5%), and others (9%, defined as anemia not otherwise specified, abdominal pain, nausea and vomiting, diarrhea, and weight loss). The overall diagnostic yield was 42 %. Gastrointestinal bleeding had the highest yield, at 44% (in-patient gastrointestinal blood loss 51%, outpatient gastrointestinal blood loss 40%; P=0.1314). Patients with iron-deficiency anemia had a yield of 42%, and patients with a previous abnormal radiograph had a yield of 41%. The combined diagnostic yield for the indications in the "other" category was 21% --significantly lower than in patients with gastrointestinal bleeding, abnormal radiographs, and iron deficiency (P=0.049). SBE is safe and useful in the evaluation of small-bowel disease. Although the overall yield is highly dependent on the specific indication, it is effective for patients with in-patient or outpatient gastrointestinal blood loss, patients with abnormal radiographs that demonstrate small-bowel pathology considered to be within reach of the enteroscope, and iron-deficiency anemia. There are insufficient data to support the use of enteroscopy for other indications such as anemia not otherwise specified, abdominal pain, nausea and vomiting, and chronic diarrhea, and in these cases it is unlikely to be useful.

A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease

Background & Aims: This study was undertaken to prospectively compare the clinical outcomes of small bowel radiographs with the wireless capsule endoscopy. Methods: Twenty-two patients were selected consecutively because of suspected small bowel disease. Two patients were excluded owing to ileal stenosis. Thus, the results of barium follow-through and the Given M2A wireless video capsule (Given Imaging Ltd., Yoqneam, Israel) endoscopy were compared in 20 patients (13 men; mean age, 52.5 yr; range, 29–78 yr). Results: Barium follow-through was normal in 17 patients and showed ileal nodularity in 3 patients. Capsule endoscopy was normal in 3 patients and showed positive findings in the remaining 17 patients. The barium study was considered diagnostic in 4 (20%) patients. The capsule endoscopy was considered diagnostic in 9 (45%) patients, suspicious in 8 (40%) patients, and failed in 3 (15%) patients. For obscure gastrointestinal (GI) bleeding, the diagnostic potential of barium follow-through was much worse as compared with the capsule endoscopy (5% vs. 31%, P < 0.05). Capsule endoscopy was well tolerated and better accepted by patients when compared with the most recently performed endoscopic procedure. Conclusions: The video capsule endoscope was found to be superior to small bowel radiograph for evaluation of small bowel diseases. However, this novel wireless endoscope system needs further assessment because of limitations such as difficulties in interpretation of potentially nonspecific findings.GASTROENTEROLOGY 2002;123:999-1005

Intraoperative enteroscopy in the evaluation of small bowel disease: case studies, indications, and treatment algorithms

Intraoperative enteroscopy in the evaluation of small bowel disease: case studies, indications, and treatment algorithms