Mid Small Bowel Research Articles

Utility of CT for Diagnosis and Management of Small Bowel Obstruction

Wang Q, Chavhan G, Babyn P, et al. Utility of CT in the diagnosis and management of small-bowel obstruction in children. Pediatr Radiol. 2012; 42 (12): 1441– 1448; doi: 10.1007/s00247-012-2497-9[OpenUrl][1][CrossRef][2][PubMed][3] Researchers from The Hospital for Sick Children in Toronto sought to determine the sensitivity of multidetector computed tomography (CT) in identifying the presence, location, and cause of small bowel obstruction (SBO) in children. The investigators analyzed records of children who underwent an abdominal CT for possible SBO at their institution and then subsequently underwent confirmatory abdominal surgery from 2000 to 2010. Two pediatric radiologists reviewed the CT images for signs of obstruction, including presence of small bowel dilation, wall thickening, presence and location of transition points, small bowel feces sign (inspisated feces in a dilated loop of small bowel), and contrast enhancement of the bowel wall, as well as other signs associated with SBO such as air-fluid levels and collapsed bowel beyond an obstruction. The location of obstruction (ie, duodenum, proximal jejunum, mid small bowel, and distal ileum) as well as the cause of SBO were assessed. Reports of plain films of the abdomen performed prior to the CT were also reviewed for the presence, absence, or equivocal findings of SBO. The investigators also … [1]: {openurl}?query=rft.jtitle%253DPediatric%2Bradiology%26rft.stitle%253DPediatr%2BRadiol%26rft.aulast%253DWang%26rft.auinit1%253DQ.%26rft.volume%253D42%26rft.issue%253D12%26rft.spage%253D1441%26rft.epage%253D1448%26rft.atitle%253DUtility%2Bof%2BCT%2Bin%2Bthe%2Bdiagnosis%2Band%2Bmanagement%2Bof%2Bsmall-bowel%2Bobstruction%2Bin%2Bchildren.%26rft_id%253Dinfo%253Adoi%252F10.1007%252Fs00247-012-2497-9%26rft_id%253Dinfo%253Apmid%252F23052726%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1007/s00247-012-2497-9&link_type=DOI [3]: /lookup/external-ref?access_num=23052726&link_type=MED&atom=%2Faapgrand%2F29%2F4%2F40.atom

Spiral Deep Enteroscopy for Removal of Small Bowel Foreign Bodies

Purpose: Traditionally, treatment of foreign body retention in the small bowel has been the purview of general surgeons. With the advent of device assisted deep enteroscopy, gastroenterologists now have the tools to retrieve foreign bodies while sparing patients from surgical intervention. Spiral enteroscopy is a device that uses a spiral overtube to pleat the small bowel back upon the enteroscope allowing deep intubation of the small bowel. We present a case series using a spiral overtube to retrieve small bowel foreign bodies. Case 1: A 70 year old male presented with abdominal pain. CT scan revealed a 2cm linear hyperdensity in the mid jejunum with focal inflammation. The patient underwent Spirus assisted deep enteroscopy. In the mid jejunum, a fish bone was seen piercing the small bowel mucosa with associated ulcer and edema. The fish bone was grasped using a forceps and extracted. The bone was then carefully withdrawn, brought into the overtube and removed from the patient. The patient was carefully observed post-procedure and had no complications. Surgery was successfully avoided. Case 2: A 45 year old male presented for removal of his PEG tube. Upon removal, the inner bumper broke off and remained in the patient's stomach. He was followed conservatively to await passage. After 4 weeks, a CT scan showed the bumper to be in the mid-distal jejunum. Spirus assisted deep enteroscopy was performed. Using a snare, the bumper was firmly grasped and carefully withdrawn from the patient's mid jejunum. Case 3: A 57 year old woman underwent video capsule endoscopy. Upon review of the images, the capsule appeared to be retained at a stricture within the mid small bowel. The patient was asymptomatic and discharged home. He followed-up in the GI clinic 1 month later noting intermittent cramping abdominal pain. The patient underwent Spirus assisted deep enteroscopy. The video capsule was retrieved using a Roth net. The stricture was then dilated without complication. Here we present cases where we used spiral enteroscopy for removal of foreign bodies. The objects were removed without significant complications. Spiral enteroscopy is a relatively new technology which allows a rapid yet controlled evaluation of the small bowel. There have been case studies involving double balloon enteroscopy and single balloon enteroscopy for successful removal of foreign objects. To date, there are not many published case reports regarding foreign body removal via spiral enteroscopy. In conclusion, spiral enteroscopy appears to be a useful tool for removal of foreign bodies from deep in the small intestine and can be considered as an alternative to surgical management.

Small Bowel Spindle Cell Capillary Type Hemangioma Diagnosed by Capsule Endoscopy in Elderly Female-A Rare Case Scenario

Purpose: A 65 year old female, with a past medical history of CABG, CAD with stents, diabetes mellitus and hypertension, was hospitalized for acute exertional chest pain and increasing shortness of breath over the past few months. She denied any history of hematochezia or melaena. Her clinical exam was essentially normal, except strongly hemo-occult positive stool. On admission, the patient's hemoglobin (Hgb) was 6.7 g/dl, hematocrit-20.2%, MCV-74.7 FL, RDW-16.8%. She received two units of PRBC. A comprehensive cardiac workup was normal. CT scan of abdomen and pelvis was normal. Upper endoscopy and colonoscopy did not reveal any source of bleeding. The patient was discharged on 9/6/11, with a Hgb of 10.7 g/dl, to be followed as outpatient. On her follow-up visit, her Hgb had decreased further at 9.9 g/dl. On subsequent capsule endoscopy, a small bowel ulcerated tumor was discovered in mid small bowel. On Ex-lap the lesion was found and resected. The pathology reported an ulcerated, lobulated spindle cell capillary type hemangioma, a rare tumor, primarily seen in pediatric patients. This case report highlights the importance and the benefits of capsule endoscopy in diagnosing small bowel tumors in elderly patients, often difficult to prepare for GI procedures, presenting with bleeding of unknown etiology. Small bowel hemangiomas are rare in the elderly1. Patients with hemangiomas can present with bleeding [acute or occult] or with perforation or obstruction.1 The most common hemangiomas of the GI tract are usually mixed type, usually of the cavernous type, rarely the capillary type 6. Ulcerated tumors can bleed slowly and cause microcytic hypochromic anemia. Capsule endoscopy is generally safe in the elderly, even in those with significant cardiac history and should be considered early in the work-up. Timely surgical intervention can prevent fatal complications like massive bleeding, obstruction and complications secondary to anemia.

Bevacizumab as a Novel Treatment for Gastrointestinal Angioectasias

Purpose: Gastrointestinal angioectasias (GA) are the leading cause of obscure overt and obscure occult gastrointestinal bleeding. In certain patients especially those with co morbidities and multiple lesions, current therapeutic approaches are ineffective in the prevention and recurrence of bleeding secondary to these lesions. Consequently, the demand for a safe, systemic and durable form of treatment is necessary. GA are known to strongly express vascular endothelial growth factor (VEGF).1 Beviczumab is a known inhibitor of VEGF had been shown to be effective in reducing bleeding episodes in Osler's disease.2 Our hypothesis was that bevacizumab would be effective in compassionate use in treating patients with non hereditary gastrointestinal angioectasias who had failed other therapies. Methods: We followed three patients ages 74, 74 and 75, requiring multiple transfusions. Each patient failed endoscopic therapy or was not a candidate for other forms of treatment. The Institutional review board approved the use of bevacizumab. Each patient received 10 mg/kg on the first infusion, followed by two 5 mg/kg infusions. Patient no. 1 had angioectasias in the stomach and throughout the small bowel. Patient no. 2 had angioectasias in the stomach and duodenum. Patient no. 3 had angioectasias in the mid-small bowel, terminal ileum and mid-transverse colon. Patients were followed for a mean of 4.5 months to detect changes in their hemoglobin, number of transfusions, hospitalizations and endoscopic interventions. Results: All three patients had improvements in their hemoglobin with an average increase of hemoglobin of 17.6% (range 3%-24%) after treatment with bevacizumab. Additionally, there was a decrease in the average number of transfusions by 61.7%. Furthermore, all patients required less endoscopic interventions and less hospitalizations. Conclusion: Inhibition of angiogenesis through with bevacizumab may be an effective and safe in treating patients with angioectasias. Prospective randomized controlled trials will need to be performed to determine the true effect of bevacizumab.

Intestinal Tuberculosis Mimicking Inflammatory Bowel Disease as an Initial Presentation of AIDS

Purpose: A 44-year-old African-American male presented with three months of right-sided abdominal pain and two weeks of bloody diarrhea, fevers and 20-pound weight loss. CT showed necrotic mesenteric lymphadenopathy and reactive thickening of the mid-small bowel; patient preferred workup as an outpatient. Three months later, he presented with pancytopenia and was diagnosed with HIV and CD4 count of 54. After six months of HAART, the mesenteric lymphadenopathy improved. Infection, neoplasm and inflammatory bowel disease were considered, but the patient was reluctant to undergo further workup. He eventually developed progressive abdominal pain and small bowel obstruction. Colonoscopy revealed friable, edematous mucosa in the terminal ileum and a fungating, ulcerated mass at the ileocecal valve with multiple ulcers throughout the ascending colon and cecum. Pathology of the mass showed poorly formed granulomas with multinucleated giant cells. Testing for CMV, HSV, AFB, Yersinia, and fungal organisms were negative. Mesenteric lymph node biopsy showed necrotizing granulomatous inflammation, but culture was negative. One month later, ileocecal AFB culture grew Mycobacterium tuberculosis (MTB). He was started on 4-drug MTB therapy with improvement in his symptoms and imaging. MTB is a rare cause of colitis in the industrialized world. In countries where the disease is endemic, MTB colitis is common and often indistinguishable from Crohn's Disease. Both disorders cause similar granulomatous change, mucosal erythema, ulceration, and nodularity. Abdominal MTB can involve the peritoneum, intestines, intraabdominal lymph nodes, and liver. Ninety percent of cases in the GI tract affect the ileocecal region. Pulmonary involvement is present in up to 50% of patients with GI MTB. In patients with HIV/AIDS, immune reconstitution after initiation of anti-retrovirals is associated with worsening of MTB infection in up to 40% of cases, and worsening can be seen after initiation of anti-MTB therapy as well. Though rare, TB colitis should be considered in patients with symptoms and imaging suggestive of colonic ulceration and inflammation. A high index of suspicion is essential in timely diagnosis and management of GI MTB.Figure: [1194]

A Very Obscure Gastrointestinal Bleeding

Question: A 62-year-old man was referred to our unit for intermittent obscure–overt gastrointestinal bleeding for 2 months requiring up to 3 units of packed red blood cells weekly. His clinical history was noteworthy for urgent right hemicolectomy owing to right-sided colonic diverticulitis 8 years before this admission. Upper and lower endoscopy and angiography were negative. On admission, he presented with melena; he was hemodynamically stable and his hemoglobin level was 68 g/L. After red blood cell replacement, he underwent small bowel capsule endoscopy disclosing a tiny, round, bulls-eye shaped mucosal break, located in the mid small bowel (52% of the time elapsed from the pylorus; Figure A, arrows).

Jejunal Amyloidosis: A Rare Cause of Severe Gastrointestinal Bleeding

1Department of Medicine; 2Division of Pathology; 3Division of Gastroenterology, University of British Columbia, Royal Columbian Hospital, New Westminster, British Columbia Correspondence: Dr Justin Cheung, Department of Gastroenterology, Royal Columbian Hospital, 410-301 East Columbia Street, New Westminster, British Columbia V3L 3W5. Telephone 604-525-0155, fax 604-525-1699, e-mail justa48@hotmail.com Received for publication December 22, 2011. Accepted December 29, 2011 CASE PRESENTATION An 81-year-old Jamaican woman presented with melena and severe anemia, and a hemoglobin level of 47 g/L (normal range 115 g/L to 160 g/L). A gastroscopy and colonoscopy were negative for any lesions. Duodenal biopsies were normal. A subsequent computed tomography scan of the abdomen with contrast showed diffuse thickening from the jejunum to the distal small bowel and a small area of active bleeding in the mid small bowel. A technetium-99m red blood cell scan demonstrated active bleeding in the proximal jejunum. Push enteroscopy (120 cm to 150 cm below incisor) revealed mild diffuse friability starting from the proximal jejunum, as well as erosions, nodularities, polypoid protrusions and valvulae conniventes thickening in the remaining jejunum (Figures 1A and 1B). Jejunal biopsies showed extensive amyloid deposition in the lamina propria and submucosa, with Congo red stain demonstrating apple-green birefringence under polarized light (Figure 2), and hematoxylin counterstain revealing amorphous, salmon-pink, sparsely cellular hyaline material (Figure 3). Serum protein electrophoresis, immunofixation and a serum-free light chain assay confirmed the presence of monoclonal immunoglobulin G lambda paraprotein. The patient was transfused with packed red blood cells as needed (average one unit per day), and treated with bortezomib and dexamethasone for primary amyloidosis. By day 17 of hospitalization, the bleeding had resolved and the patient was subsequently discharged without any further bleeding episodes. DISCUSSION Amyloidosis is a multisystem disease characterized by extracellular deposition of abnormal protein fibrils in various tissues and organs. The protein fibrils are derived from monoclonal immunoglobulin light chains in primary amyloidosis (AL), acute phase reactant serum amyloid A in secondary amyloidosis (AA), and beta2-microglobulin in dialysis-related amyloidosis (Ab2m). Clinical manifestations in amyloidosis are variable, but the heart and kidneys are most commonly involved. Gastrointestinal symptoms due to bleeding, dysmotility and malabsorption are present in up to 60% of AA (1), but in only 1% of AL (2). The diagnosis of amyloidosis can only be confirmed by tissue biopsy because endoscopic and radiologic findings are nonspecific. Therapy is directed at the underlying cause in AL (plasma cell dyscrasia) and AA (infection, inflammation and malignancy), whereas treatment in Ab2m involves alteration of dialysis mode or consideration of renal transplantation (3). Severe gastrointestinal bleeding rarely occurs as the sole or initial manifestation of systemic amyloidosis (4). Mechanisms by which hemorrhage occurs in gastrointestinal amyloidosis have been postulated, including intestinal ischemia, necrotic ulceration, mucosal tearing, vascular fragility, abnormal platelet aggregation, and factor IX and X deficiencies (5,6). In addition to supportive care for bleeding, treatment must be tailored to the specific type of amyloidosis, as determined by endoscopy and histology. Endoscopy classically shows polypoid protrusions and valvulae conniventes thickening in AL; a imAge of the month

Simultaneous caecal volvulus through a congenital mesenteric defect and proximal intussusception

A 55-year-old man presented with acute vomiting and abdominal distension. He had three prior hospital admissions over the previous year for similar symptoms, which resolved spontaneously within a short time. Plain abdominal X-rays showed a grossly dilated caecum occupying the left upper quadrant consistent with a caecal volvulus. This was confirmed on CT scan, which also showed a dilated stomach and proximal duodenum and a collapsed midsmall bowel. An unsuccessful attempt was made to deflate the patient by colonoscopy. The patient was taken to the operating room that night where laparotomy revealed a grossly distended caecum due to caecal volvulus (Fig. 1) that was initially deflated by needle caecostomy. Dissection of the right colon showed the caecum herniating through a congenital mesenteric defect located in the terminal ileal mesentery (Fig. 2). The defect was enlarged with a performance of standard stapled right hemicolectomy. Proximal assessment of the small bowel also showed a mid-jejunal intussusception with no obvious leading point (Fig. 3) which was reduced. There was no associated intraabdominal lymphadenopathy. The patient underwent small bowel resection and anastomosis. Histology confirmed

Improved Video Quality and Reliability With Self-Stabilizing Colon Capsule Endoscopy: Pilot Study in Acute Canine Models

previous investigations. Results: A total of 580 double-balloon enteroscopy procedures were carried out. Anterograde (oral) and retrograde (anal) route double-balloon enteroscopies were performed in 359 and 221 patients, respectively. A total of 48 patients were found to have neoplastic disease/masses. Thirty-five tumours were detected prior to DBE (33 by capsule enteroscopy and 2 by Computer tomography), 9 were suspected by CE but found only at DBE and 2 cases were missed by CE altogether. Twenty-one tumours were found at retrograde DBE, whilst 27 were found at antegrade DBE. 46 patients presented with OGIB, where 2 presented with abdominal pain. The distribution of lesions was duodenum 5, jejunum 22, mid small bowel 16 and ileum 5. Morphologically, 2 were infiltrative, 7 were pedunculated, and the remainder were sub mucosal. At DBE 13 were inspected only, 25 were biopsied, 6 were tattooed for potential surgery and 4 were resected endoscopically. The final pathology was: 9 small sub mucosal lesions with normal biopsy (normal histology), 4 adenomas , 3 lymphomas , 3 lymphangitic cysts, 2 adenocarcinomas , 1 Meckels diverticulum, 1 hamartoma, 1 lymphoid hyperplasia, 1 lipoma, and 1 metastatic melanoma. Eighteen patients avoided surgery (diagnosis made and observation only), 4 resected by endoscopy, 3 underwent surgery (adenocarcinoma with invasive infiltration), and 3 underwent chemotherapy for lymphoma. Conclusions: Our analysis shows that small bowel tumours are a significant finding at double-balloon enteroscopy and that this procedure has a therapeutic impact on the management of suspected or documented small bowel neoplasia.

Is there an association between diarrhoea predominant irritable bowel syndrome and small bowel injury on capsule endoscopy?

IntroductionDiarrhoea predominant irritable bowel syndrome (D-IBS) represents a large outpatient gastroenterology workload. There are a subset of patients where their symptoms of D- IBS may overlap with suspected Crohn's disease....

Impact of capsule endoscopy on management in patients with established crohn's disease-experience from a single tertiary centre

IntroductionCapsule endoscopy (CE) has developed a pertinent role in the management of patients with Crohn's disease, however there is a paucity of literature assessing the long term impact of CE....

Tu1556 A Novel Motorized Spiral Enteroscope Can Advance Rapidly, Safely and Deeply Into the Small Bowel

Current spiral technology technique requires an overtube with a raised spiral at the distal end. In published studies, the technique achieves consistent mid small bowel intubation but requires 2 operators and facility with operating an overtube. Our hypothesis was that an integrated motorized spiral enteroscope would be faster, achieve deeper intubation and have excellent control with a single operator simplified technique.

NSAID-induced deleterious effects on the proximal and mid small bowel in seronegative spondyloarthropathy patients

To investigate the small bowel of seronegative spondyloarthropathy (SpA) patients in order to ascertain the presence of mucosal lesions. Between January 2008 and June 2010, 54 consecutive patients were enrolled and submitted to a video capsule endoscopy (VCE) examination. History and demographic data were taken, as well as the history of non-steroidal anti-inflammatory drug (NSAID) consumption. After reading each VCE recording, a capsule endoscopy scoring index for small bowel mucosal inflammatory change (Lewis score) was calculated. Statistical analysis of the data was performed. The Lewis score for the whole cohort was 397.73. It was higher in the NSAID consumption subgroup (P = 0.036). The difference in Lewis score between NSAID users and non-users was reproduced for the first and second proximal tertiles of the small bowel, but not for its distal third (P values of 0.036, 0.001 and 0.18, respectively). There was no statistical significant difference between the groups with regard to age or sex of the patients. The intestinal inflammatory involvement of SpA patients is more prominent in NSAID users for the proximal/mid small bowel, but not for its distal part.

Intestinal Adaptation for Oligopeptide Absorption via PepT1 After Massive (70%) Mid-Small Bowel Resection

IntroductionProteins are absorbed primarily as short peptides via peptide transporter 1 (PepT1). HypothesisIntestinal adaptation for peptide absorption after massive mid-small intestinal resection occurs by increased expression of PepT1 in the remnant small intestine and colon. MethodsPeptide uptake was measured in duodenum, jejunum, ileum, and colon using glycyl-sarcosine 1 week (n = 9) and 4 weeks (n = 11) after 70% mid-small bowel resection and in corresponding segments from unoperated rats (n = 12) and after transection and reanastomosis of jejunum and ileum (n = 8). Expression of PepT1 (mRNA, protein) and villus height were measured. ResultsIntestinal transection/reanastomosis did not alter gene expression. Compared to non-operated controls, 70% mid-small bowel resection increased jejunal peptide uptake (p < 0.05) associated with increased villus height (1.13 vs 1.77 and 1.50 mm, respectively, p < 0.01). In ileum although villus height increased at 1 and 4 weeks (1.03 vs 1.21 and 1.35 mm, respectively; p < 0.01), peptide uptake was not altered. PepT1 mRNA and protein were decreased at 1 week, and PepT1 protein continued low at 4 weeks. Gene expression, peptide uptake, and histomorphology were unchanged in the colon. ConclusionsJejunal adaptation for peptide absorption occurs by hyperplasia. Distal ileum and colon do not have a substantive role in adaptation for peptide absorption.

A Case of a Patient with a Benign Cyst Presenting as a Submucosal Small Bowel Mass on Wireless Capsule Endoscopy Prompting Double Balloon Endoscopy

Purpose: An 82-year-old female with a one year history of iron deficiency anemia. She underwent an EGD and colonoscopy by an outside gastroenterologist which revealed erythema throughout the stomach and a healing ulcer. Colonoscopy revealed a non-bleeding cecal AVM. Twice daily proton pump inhibitor was continued, but one month later, the patient was admitted to an outside hospital with syncope and a hematocrit of 26 requiring blood transfusion. Her aspirin was held. A follow-up EGD was unremarkable. Subsequently, a wireless capsule enteroscopy found a submucosal mass in the mid-small bowel. She was referred to our institution for consideration of double balloon endoscopy. She reported a good appetite without pyrosis or nausea and a 20 lb weight loss earlier in the year, but a stable weight within the past few months. She denied any visible blood in her stools or black stools. Her hematocrit had stabilized at 37. A double-balloon endoscopy was performed from oral route under general anesthesia. The scope was advanced to 200cm and a soft, yellow, submucosal lesion, measuring approximately 2 cm of similar appearance to the video capsule image was identified. The lesion was biopsied with immediate collapse of the lesion suggesting a submucosal cyst. The total procedure time took 2 hours. Tissue biopsy showed small intestinal mucosa with a thin band of fibrotic tissue suggesting a simple cyst that was incidentally discovered on video capsule. Discussion: In 2001, the FDA approved the first wireless capsule endoscopy to detect small bowel pathology. Previously, small bowel access had been limited. Double balloon endoscopy is now being performed in certain specialized tertiary care centers. It may be used in conjunction with wireless capsule endoscopy, particularly if a small bowel mass or bleeding source is identified. We present a case report of a patient who underwent double balloon endoscopy after wireless capsule endoscopy demonstrated a submucosal mass. After biopsy, the lesion collapsed and pathology confirmed this benign, simple cyst in the small bowel to be an incidental finding which was not felt to be contributing to her iron deficiency anemia.Figure

The Society for Gastrointestinal Intervention. Are We, as an Organization of Disparate Disciplines, Cooperative or Competitive?

The Society for Gastrointestinal Intervention. Are We, as an Organization of Disparate Disciplines, Cooperative or Competitive?

Single-balloon enteroscopy: results from an initial experience at a U.S. tertiary-care center

Single-balloon enteroscopy (SBE) is a novel, deep-enteroscopy modality for diagnosis and treatment of disorders of the small bowel. The aim of the study was to examine the performance, yield, and safety of SBE in the initial experience at a tertiary-care center. Retrospective analysis of all SBEs during a 10-month period in 2008. Data were extracted from electronic clinical and endoscopy records. U.S. tertiary-care center. All patients referred to our center for SBE during the study period were included in the current analysis. SBE. Anterograde SBE procedure time, diagnostic yield, and complications. Thirty-eight anterograde SBEs were performed. The mean patient age was 62 years (42% female). Patients were referred for GI bleeding (97%), Crohn's disease, suspected polyps or neoplasia, and abnormal capsule endoscopy results. The mean (+/- SD) procedure time was 49 +/- 19 minutes. The estimated depth of insertion was proximal jejunum (34%), mid-jejunum (45%), and distal jejunum (21%). The SBE diagnostic yield was 47%, with significant findings in 18 patients. Findings included angiectasias, bleeding, abnormal mucosa, ulceration, polyps, and a foreign body. The therapeutic yield was 42%, with lesion ablation performed in 24% of cases. Diagnostic biopsies were performed in 24% of cases and tattooing in 52%. There were no significant complications. Single-center, retrospective study. Single-balloon enteroscopy appears to be a safe and efficient method for examination of the mid-small bowel. The significant therapeutic yield (42%) suggests that comparative studies with double-balloon and spiral enteroscopy are warranted.

PTH-067 Cost minimising introduction of wireless capsule endoscopy

<h3>Introduction</h3> National Institute for Health and Clinical Excellence approved the use of relatively expensive capsule endoscopy (CE) to investigate mid gastrointestinal haemorrhage (MGIH) and small bowel Crohn9s disease (CD) in 2004. It gives a high diagnostic yield (31–76% MGIH, 43–71% CD), does not use radiation and causes few complications. In the past cheaper contrast fluoroscopy was the investigation of choice. Robust data that compare the two are limited. Which minimises costs when used in a public general hospital? <h3>Methods</h3> As part of our service audit we used electronic records to identify all patients who had had CE±fluoroscopy to investigate MGIB or CD at our institution from January 2007 to May 2008. (Patients referred from elsewhere for CE were excluded.) We established the indication for investigation, other tests that had been done and the positive diagnostic yield for each. We used activity based costing to determine procedure costs. We then constructed a cost minimising pathway for patient investigation for MGIB and CD and subjected our conclusions to sensitivity analyses. <h3>Results</h3> For CD investigation, 136 patients had fluoroscopy, 21 CE and 3 both. For MGIH 47 had fluoroscopy, 59 CE and 8 had both. The positive diagnostic yield for CD was 23% with fluoroscopy, approximate half that of CE (57%) and for MGIH, 2% with fluoroscopy and 56% with CE. Observation of actual practice suggests that both positive and negative fluoroscopy results may help clinicians conclude investigation of suspected CD in that few of the patients we studied had had both investigations. It appeared that the investigations in themselves were rarely definitive and were interpreted in the clinical context of individual patients. Relative costs for CE in the UK range from £1075 to 1368 and fluoroscopy £146–288. Fluoroscopy detects approximately half the CD cases that CE would at less than a quarter of the cost of CE. <h3>Conclusion</h3> To investigate CD, our analysis suggests that fluoroscopy should be used initially and only if negative and clinical suspicion of CD remains should CE then be done. The very low diagnostic yield for fluoroscopy vs. CE for MGIH demands that CE should be the imaging modality of choice and fluoroscopy abandoned as a diagnostic option. To determine the place for new, often expensive, investigation techniques cost minimisation analysis is effective. We estimate that, for our patient cohort, the use of CE as the first investigation for MGIH and only after a negative fluoroscopy study for suspected CD, our institution could have saved ∼£7000. Extrapolating these figures nationally the judicious use of CE has the potential to save the NHS £1.3 million per annum. The analysis does not factor in other CE benefits such as faster diagnosis of MGIH and less radiation exposure.

Minimal incision laparotomy assisted endoscopic resection for polyps in small intestine in patients with Peutz-Jeghers syndrome

Objective To evaluate the effectiveness and safety of minimal incision laparotomy assisted endoscopic resection for polyps in small intestine in patients with Peutz-Jeghers syndrome. Methods The clinical data of patients with Peutz-Jeghers syndrome, who underwent minimal incision laparotomy assis- ted endoscopic resection for polyps in small intestine, were retrospectively studied. The size and number of the endoscopically resected polyps, and the procedure related complications were documented. Results A total of 812 polyps in small-bowel were resected in 8 patients, in which 384 were smaller than 10mm, 356 with diameter ranging from 11 mm to 30mm, and 72 were larger than 30mm in diameter. Procedure related complications included intestinal dysfunction in 1 patient and abdominal pain in another. No bleeding with a fall in Hb or other severe complications were observed. Conclusion Minimal incision laparotomy assisted endoscopic resectio is a safe and reliable procedure for the treatment of mid-small bowel polyps in patients with Peutz-Jeghers syndrome. It revolutionizes the therapeutic options for polyps in the region of the midsmall bowel and limits the indications for primary surgical management. Key words: Peutz-Jeghers syndrome ; Intestinal polyp ; Laparotomy; Endoscopy

Lubiprostone neither decreases gastric and small-bowel transit time nor improves visualization of small bowel for capsule endoscopy: a double-blind, placebo-controlled study

Lubiprostone, a selective activator of type 2 chloride channels, is approved for treatment of chronic idiopathic constipation and recently constipation-predominant irritable bowel syndrome. It has been suggested that lubiprostone has a prokinetic effect. This investigation was designed to evaluate lubiprostone as a preparation and propulsive agent for small-bowel capsule endoscopy. The PillCam Small Bowel capsule endoscopy system with the PillCam SB1 capsule and Rapid 5 software platform were used. The study was designed as a double-blind, placebo-controlled trial. Forty healthy adults. Gastric transit time (GTT), small-bowel transit time (SBTT), and adequacy of small-bowel cleansing preparation. The study subjects received 24 mug lubiprostone or placebo 30 minutes before PillCam capsule ingestion. Capsule endoscopy studies were read by 2 independent investigators unaware of the study medication received, and differences in interpretation were resolved by consensus. Anatomical landmarks were identified, and GTT and SBTT were calculated. Overall preparation quality assessment of the proximal, mid, and distal small bowel was determined by using a 4-step scale. The percentage of visualized bowel was determined by review of 10-minute video segments at 1-hour intervals after the capsule passed through the pylorus. In the lubiprostone group (n = 20), 2 subjects did not pass the capsule through the pylorus in the 8-hour battery life of the capsule. An additional 3 capsules did not pass into the colon. In the placebo group (n = 20), all capsules passed into the small bowel, but 1 did not pass into the colon. The subjects in whom the capsule did not pass into the small bowel were excluded from the small-bowel analysis. In the subjects in whom the capsule did reach the colon, the SBTT could not be calculated and they were excluded from SBTT analysis. The mean GTT in the lubiprostone group was 126 minutes and 43 minutes in the placebo group (P = .0095). The mean SBTT in the lubiprostone group was 188 minutes and 219 minutes in the placebo group (P = .130). The overall preparation assessment of the small bowel was not statistically significant between the 2 groups in the proximal, mid, or distal small bowel (proximal, P = .119; mid, P = .118; distal, P = .121). There was no significant difference in lubiprostone compared with placebo in the percentage of visualized small bowel. Some capsules did not leave the stomach or reach the cecum. Lubiprostone produced a significant increase in GTT but did not result in a significant decrease in SBTT compared with placebo. The administration of lubiprostone before capsule ingestion did not result in improved overall preparation of the small bowel for capsule endoscopy or increase the percentage of visualized small bowel. (The trial was registered at www.clinicaltrials.gov, identifier NCT00746395.).