Negative Bidirectional Endoscopy Research Articles

Impact of capsule endoscopy on outcome in mid-intestinal bleeding: a multicentre cohort study in 285 patients

Capsule endoscopy (CE) sensitively detects the bleeding source in the small bowel. However, the influence of CE on long-term outcome is not well established. In five tertiary hospitals, all CE investigations were retrospectively identified dating back to 3 years. Patients with intestinal bleeding and negative bidirectional endoscopy were included, and relapse of bleeding was recorded. A bleeding source was detected in 219 of 285 patients (76.8%); CE provided the diagnosis in 175 of 219 (79.9%) and other, repeated investigations in 44 cases (20.1%). Follow-up (mean+/-SD=20.7+/-9.4 months) in 240 patients identified rebleeding in 65 (27.1%), and readmission to a hospital in 42 (17.5%). Hospital readmission was most frequent in patients with angiectasias (31.3%, relative risk (RR)=5.0; 95% confidence interval (CI)=2.4-10.4). Other risk factors included patients being older than 60 years of age (RR=3.8; 95% CI=1.5-9.5), and anticoagulant medication (RR=3.0; 95% CI=1.5-6.0). Therapeutic measures had a mean recurrence rate of 3.7% in surgical candidates (Meckel's diverticulum, tumor), 40% in endoscopically treated and 16% in medically treated patients. In case all the detected angiectasias had been cauterized, the relapse rate was low (11.8%), but in incompletely treated patients, it was high (85.7%). Bleeding relapse was never lethal. CE guides therapeutic measures and predicts the risk of recurrent bleeding in small intestinal bleeding. High risk of rebleeding in angiectasias is significantly reduced by the cauterization of all demonstrable lesions.

Small-bowel neoplasms in patients undergoing video capsule endoscopy: a multicenter European study

Small-bowel tumors account for 1% - 3% of all gastrointestinal neoplasms. Recent studies with video capsule endoscopy (VCE) suggest that the frequency of these tumors may be substantially higher than previously reported. The aim of the study was to evaluate the frequency, clinical presentation, diagnostic/therapeutic work-up, and endoscopic appearance of small-bowel tumors in a large population of patients undergoing VCE. Identification by a questionnaire of patients with VCE findings suggesting small-bowel tumors and histological confirmation of the neoplasm seen in 29 centers of 10 European Countries. Of 5129 patients undergoing VCE, 124 (2.4%) had small-bowel tumors (112 primary, 12 metastatic). Among these patients, indications for VCE were: obscure gastrointestinal bleeding (108 patients), abdominal pain (9), search for primary neoplasm (6), diarrhea with malabsorption (1). The main primary small-bowel tumor type was gastrointestinal stromal tumor (GIST) (32%) followed by adenocarcinoma (20%) and carcinoid (15%); 66% of secondary small-bowel tumors were melanomas. Of the tumors, 80.6% were identified solely on the basis of VCE findings. 55 patients underwent VCE as the third procedure after negative bidirectional endoscopy. The lesions were single in 89.5% of cases, and multiple in 10.5%. Retention of the capsule occurred in 9.8% of patients with small-bowel tumors. After VCE, 54/124 patients underwent 57 other examinations before treatment; in these patients enteroscopy, when performed, showed a high diagnostic yield. Treatment was surgery in 95% of cases. Our data suggest that VCE detects small-bowel tumors in a small proportion of patients undergoing this examination, but the early use of this tool can shorten the diagnostic work-up and influence the subsequent management of these patients.

Small Bowel Tumors Detected By Video Capsule Endoscopy (VCE): Preliminary Data from the ECEG (European Capsule Endoscopy Group) Database

Background: Small bowel (SB) tumours account for little more than 1% of GI neoplasms. These malignancies become symptomatic after a long silent phase and often represent a diagnostic challenge. Recently, the endoscopic evaluation of the SB became easier, painless and safe because of the introduction of the Video Capsule Endoscopy (VCE) in clinical practice. This diagnostic tool identified more small bowel neoplasms than previously expected. Aim of the study: To describe the clinical presentation, the diagnostic work-up, the endoscopic appearance of SB tumours identified by VCE in a large population of patients. Patients and methods: We collected patients with capsule endoscopy findings suggesting SB tumours and further histological confirmation of the neoplasm. Results: Among 3031 VCE performed in 17 centres of 6 European countries, we identified 74 patients (2.4%) (32F, 42 M, mean age 59,0 + 14,7 years) with a diagnosis of small bowel tumour. In these patients the indication for VCE was obscure GI bleeding in 67 (90.5%): obscure-occult in 39,2%, obscure overt in 32,4% and previous overt in 18,9%, abdominal pain in 4 (5,5%) and research for primitive neoplasm in 3 patients with liver metastases (4%). 17 patients (23%) underwent VCE as the third test after a negative bidirectional endoscopy while 57 (62,2%) performed at least one further examination of the SB before VCE. The endoscopic appearance of lesions identified by VCE was: polyps in 67,7%, ulcers in 12,1%, stenoses 10,8%, fresh blood in 6,7% and cobblestone in 2,8%. The lesions were single in 87,6% of cases (63,1%, located in the jejunum, 32,3% in the ileum and 4,6% in the duodenum) and multiple in 9,4%. The VCE was retained and surgically removed in 10,9% of patients. 66 of 74 lesions identified were primitive neoplasm (36,6% GISTs, 16,6% carcinoids, 13,6% adenocarcinomas and 33,2% other SB tumours) while the other 8 cases were SB metastases (5 cases of melanoma, 1 colonic carcinoma, 1 hepatocellular carcinoma and 1 seminoma). After VCE, 32 patients were operated on while 34 underwent another diagnostic examination before surgery; 4 patients underwent chemotherapy. Conclusions: The prevalence of SB tumours in patients underwent VCE is 2,4%. In patients with SB tumours the main indication for VCE was obscure GI bleeding; in about one quarter of cases VCE represented the third examination after negative bidirectional endoscopy. These neoplasms appear frequently as a polyp and in 10% of cases lead the capsule retention. GIST was the most frequent primitive small bowel neoplasm. The treatment, often based only on capsule endoscopy findings, was surgical in 93% of cases.

Small bowel capsule endoscopy in 2007: indications, risks and limitations.

Capsule endoscopy has revoluzionized the study of the small bowel by providing a reliable method to evaluate, endoscopically, the entire small bowel. In the last six years several papers have been published exploring the possible role of this examination in different clinical conditions. At the present time capsule endoscopy is generally recommended as a third examination, after negative bidirectional endoscopy, in patients with obscure gastrointestinal bleeding. A growing body of evidence suggests also an important role for this examination in other clinical conditions such as Crohn's disease, celiac disease, small bowel polyposis syndromes or small bowel tumors. The main complication of this examination is the retention of the device at the site of a previously unknown small bowel stricture. However there are also some other open issues mainly due to technical limitations of this tool (which is not driven from remote control, is unable to take biopsies, to insufflate air, to suck fluids or debris and sometimes to correctly size and locate lesions). The recently developed double balloon enteroscope, owing to its capability to explore a large part of the small bowel and to take targeted biopsies, although being invasive and time consuming, can overcome some limitations of capsule endoscopy. At the present time, in the majority of clinical conditions (i.e. obscure GI bleeding), the winning strategy seems to be to couple these two techniques to explore the small bowel in a painless, safe and complete way (with capsule endoscopy) and to define and treat the lesions identified (with double balloon enteroscopy).