Small Bowel Polyposis Research Articles

Advancements in endoscopic management of small-bowel polyps in Peutz-Jeghers syndrome and familial adenomatous polyposis.

Before the development of double-balloon enteroscopy (DBE), the standard management of small-bowel polyposis was surgical resection. This is an invasive procedure that could lead to short bowel syndrome. In the 21st century, several new enteroscopy techniques were distributed worldwide, including DBE, single-balloon enteroscopy, spiral enteroscopy, and motorized spiral enteroscopy. These devices enable the diagnoses and endoscopic interventions in the entire small bowel, even in patients with a history of laparotomy. In patients with Peutz-Jeghers syndrome (PJS), endoscopic ischemic polypectomy with clips or a detachable snare is the preferred method for managing pedunculated polyps because it is less likely to cause adverse events than conventional polypectomy. Although polyps in patients with PJS always recur, repeat endoscopic resection can reduce the total number and mean size of polyps in the long-term clinical course. Endoscopic reduction of small-bowel intussusception caused by PJS polyps can be successfully performed using DBE without surgery. A transparent hood is useful for securing a visual field during the treatment of small-bowel polyps, and minimal water exchange method is recommended to facilitate deep insertion. Familial adenomatous polyposis (FAP) is a genetic disorder that increases the risk of developing colorectal cancer. Because jejunal and ileal polyps in patients with FAP have the potential to develop into cancer via the adenoma-carcinoma sequence, periodical surveillance, and endoscopic resection are needed for them, not only polyps in the duodenum. In cases of multiple small-bowel polyps in patients with FAP, cold snare polypectomy without retrieval is an acceptable treatment option for polyps that are 10 mm or smaller in size. Additional good pieces of evidence are necessary to confirm these findings because this narrative review mostly includes retrospective observational studies from single center, case reports, and expert reviews.

WITHDRAWN: Updates in the diagnosis and management of non-ampullary small-bowel polyposis

WITHDRAWN: Updates in the diagnosis and management of non-ampullary small-bowel polyposis

Clinical features and long-term outcomes of patients with colonic oligopolyposis of unknown etiology.

Colonic adenomatous polyposis of unknown etiology (CPUE) is an adenomatous polyposis phenotype that resembles Familial Adenomatous Polyposis (FAP) even though no germline pathogenic variant is identified. We sought to better characterize the clinical features and outcomes in a cohort of CPUE patients. This is a retrospective case series of patients 18 years old or older with aden-omatous oligopolyposis (between 10-100 adenomas) and negative genetic testing, identified through the Hereditary Gastrointestinal Cancer Database at Massachusetts General Hospital, a tertiary academic referral center. A retrospective chart review was performed with a focus on demographics, alcohol and tobacco use, medication use, familial malignancy and polyp burden, genetic testing information, endoscopic surveillance data including the corresponding histopathology, colonic and extracolonic malignancies, mortality events, and their etiology. Spearman correlation and Pearson Chi-square test (or Fisher's exact test) were used for continuous and categorical variables respectively. CPUE patients were primarily male (69%) and presented for genetic counseling at 63.7 years. Only 2 patients (2.9%) reported a first-degree relative with polyposis. During an average surveillance period of 12.3 years, 0.5 colonoscopies per year were performed. Patients developed 2.3 new adenomas per year. 4 (5.7%) were diagnosed with colorectal cancer (CRC) at a mean age of 66 years, and 3 were diagnosed prior to the onset of oligopolyposis. 7 (10%) required colectomy due to advanced dysplasia or polyp burden. With respect to upper gastrointestinal manifestations, 1 patient had a gastric adenoma, but there were no cases of gastric or small bowel polyposis. During surveillance, 10 (14%) patients died at a mean age of 72, and none were due to CRC. CPUE is distinct from familial adenomatous polyposis (FAP) syndrome and the use of FAP surveillance guidelines may result in unnecessarily frequent upper and lower endoscopies.

Use of prokinetics and other quality factors in capsule endoscopy - old and new insights (Review).

Despite the extensive recent development of different techniques for endoscopic evaluation for both diagnostic and therapeutic reasons, the small bowel remains quite difficult to visualize. Capsule endoscopy and device assisted enteroscopy are presently considered the best diagnostic tools for examination of small bowel disorders, assessing diverse pathologies such as obscure gastrointestinal bleeding, iron deficiency anemia, Crohn disease, small bowel tumors and polyposis syndromes. Like any other imagistic method, it has specific indications, and contraindications, and possibly it is more important to consider limitations. In order to obtain a better result, it is necessary to respect the procedural quality indicators. Among them the use of prokinetics - diverse pharmacological substances increasing the success rate of capsule endoscopy have raised debates. Capsule endoscopy small bowel evaluation is a reliable, non-invasive and safe with many advantages and minimum risks, with a proper selection of patients, and can be used as first line investigation.

Acute intestinal obstruction caused by small bowel intussusception (clinical case)

One of the most difficult to diagnose and rare forms of acute intestinal obstruction is intussusception. This article presents an analysis of a clinical case of acute intestinal obstruction caused by small bowel intussusception in a patient suffering from small-bowel polyposis.

A88 EARLY-ONSET GASTRIC POLYPS IN CHILDREN WITH FAMILIAL ADENOMATOUS POLYPOSIS: A CASE SERIES

Abstract Background Familial adenomatous polyposis (FAP) syndrome is a familial inherited autosomal dominant polyposis syndrome which predisposes affected individuals to a significantly increasing risk of colorectal cancer before the age of 30 years. Studies examining the rates of duodenal and gastric neoplasia in patients with FAP are scarce. Recent reports have shown a concerning rise in gastric cancer in Western FAP patients with certain endoscopic features. Current guidelines suggest screening with gastroscopy beginning at the age of 20 to 25 years. Aims We report a case series of seven pediatric patients with evidence of early-onset upper gastrointestinal adenomatous polyps. Methods A retrospective chart review was performed for all patients diagnosed with FAP between January 2012 and December 2016 in Winnipeg Children’s Hospital which is the only pediatric tertiary-care hospital in Manitoba. A total of seven pediatric patients from 3 different families were enrolled in our case series. The following data were collected: age of diagnosis, gene mutation, time of first screening endoscopy and total number of endoscopies, number of gastric and colonic polyps, pathology results, surgeries and further routine investigations. Descriptive data were then reported on each patient. Results Five of seven patients (71.4%) exhibited maternal inheritance of the APC gene mutation. The mean age of diagnosis was 5.3 years (SE 2.4, range 2–9 years) with male predominance (n=5, 71.4%). Mean age at first colonoscopy was 9.8 years (SE 2.05; range 6.6–11.9) and 9.9 years (SE 1.88; range 6.6–11.9 years) at first gastroscopy. Five (71.4%) patients had evidence of gastric polyps and three (43%) had evidence of duodenal polyps before the age of 14 years. All patients showed an increasing burden of gastric polyposis with age. Tubular adenomas were seen in all patients who developed >50 gastric polyps (n=5), two with low-grade dysplasia diagnosed at the ages of 11 and 15 year. One patient with duodenal polyps showed tubular adenomatous changes at the age of 13.6 years. Capsule endoscopy was performed in all patients and none showed any small bowel polyposis beyond the duodenum. All seven patients had colonic tubular adenomas, two with low-grade dysplasia (at ages of 14 and 15 years) and only one without polyps at the initiation of endoscopic screening. No patients underwent surgery prior to age 15 years. Conclusions The presence of gastric and duodenal polyps in pediatric patients with FAP is not uncommon and may be underestimated. Early screening gastroscopy with gastric and duodenal biopsies should be considered at a younger age than what has currently been recommended. Funding Agencies None

Predictors of iron-deficiency anemia in primary care older adults: a real-world European multi-country longitudinal study.

Iron deficiency is a major cause of anemia in older people. Increasing the knowledge on the predictors of iron-deficiency anemia (IDA) may facilitate its timely diagnosis. To investigate the predictors of IDA in older people in four European countries. Retrospective longitudinal study. Primary care patients aged 65 or older (N = 24,051) in four European countries. IDA predictors were estimated using multivariate Cox regression based on information gathered from national primary care databases: Italy (years 2002-2013), Belgium, Germany and Spain (years 2007-2012). Adjusted hazard ratios (aHR) with 95% confidence intervals (CIs) were estimated. In Spain and Belgium, men were at greater risk of IDA than women, while they had a lower risk in Italy. Weakness, irritability, alopecia and xerostomia were signs and symptoms significantly associated with IDA. Concurrent diseases, potential causes of anemia, positively associated with IDA were small bowel polyposis, stomach cancer, obesity, gastritis and peptic ulcer, esophagitis, Crohn's disease, celiac disease, lymphangiectasis, gastrectomy or gastric atrophy, gut resection or bypass, and cardiac prosthetic valve. Aspirin users had a 12-35% higher hazard of IDA than non-users. Similarly, corticosteroids and anti-acids were positively associated with IDA. A higher level of comorbidity was associated with an increased hazard of IDA in all countries. Specific signs and symptoms, chronic conditions, a greater comorbidity burden, and specific pharmacological treatments registered in primary care databases represent relevant predictors and correlates of incident IDA in older people in Europe. General practitioners might employ this information to obtain early diagnosis of IDA in community-dwelling older adults.

Cell Intrinsic Deregulated ß-Catenin Signaling Promotes Expansion of Bone Marrow Derived Connective Tissue Type Mast Cells, Systemic Inflammation, and Colon Cancer.

Mast cells constitutively express ß-catenin and expand in solid tumors such as colon and skin cancer. However, the role of ß-catenin signaling in mast cells and the cause or effect of mast cell expansion and tumor growth has yet to be established. In earlier studies we used mast cell depletion and protease staining approaches, to provide evidence for a causative role of mast cells in small bowel polyposis, and related specific phenotypes and distributions of tumor infiltrating mast cells to stages of tumor growth. Here we report that, stabilization of ß-catenin expands mast cells to promote high incidence of colon polyposis and infrequent small bowel polyps and skin cancer. Expression of a dominant acting ß-catenin in mast cells (5CreCAT) stimulated maturation and expression of granule stored proteases. Both mucosal and connective tissue type mast cells accumulated in colonic small bowel polyps independent of gender, and mice developed chronic systemic inflammation with splenomegaly. Reconstitution of polyposis-prone mice with bone marrow from 5CreCAT mice resulted in focal expansion of connective tissue like mast cells, which are normally rare in benign polyps and characteristically expand during adenoma-to-carcinoma transition. Our findings highlight a hitherto unknown contribution of ß-catenin signaling in mast cells to their maturation and to increased risk of colon cancer.

3087 Combined Endoscopic and Surgical Management of Small Bowel Polyposis in a Patient With Peutz-Jeghers Syndrome

INTRODUCTION: A 55-year-old male with history of Peutz-Jeghers syndrome was referred for a colonoscopy for management of a large ileal polyp. Surgical history was notable for two laparatomies for small bowel obstructions in the setting of intussusception as well as multiple enterotomies for removal of polyps. CASE DESCRIPTION/METHODS: Colonoscopy confirmed a polypoid mass in the distal ileum that was partially obstructing. Endoscopic submucosal dissection of the polyp stalk was performed but revealed two feeding arteries as well as a thick muscular band, concerning for muscularis propria, that precluded further safe dissection. Hemoclips were placed on the feeding arteries in an attempt to cause necrosis of the lesion. After discharge the patient developed hematochezia. Repeat colonoscopy did not show any ongoing bleeding but the mass appeared to be necrotic. Repeat colonoscopy was planned in the operating room to evaluate the mass. If the necrosis was not complete, dissection of the stalk would be re-attempted with plans to convert to surgical resection if needed. On endoscopy, the mass appeared to have revitalized. Another attempt at submucosal dissection of the polyp stalk was performed. However as the area had already been dissected through, the submucosal plane was not easily identified in the stalk and did not feel that it was safe to continue the submucosal dissection. Subsequently, the patient was converted to surgical resection of the ileal polyp, which also revealed multiple polyps more proximally throughout the small bowel. The bowel resection included the initial large polyp and another large polyp at a prior ileal anastomosis that could not be removed without a resection. Multiple other polyps were removed via enterotomies. To clear the remaining small bowel of residual polyps, we performed a clean sweep. A pediatric colonoscope was introduced orally and the scope was able to be advanced distally to the ileal anastomosis by plicating the bowel over the scope. Multiple further polypectomies were then performed using standard endoscopic mucosal resection technique. On 3 month follow up MR enterography, there were no convincing polyps identified in the entire small bowel. DISCUSSION: This case demonstrates the importance of a multi-disciplinary approach to the management of this patient's polyposis. The combination of endoscopic and surgical approach allowed for effective management of both the large ileal polyp as well as his overall polyp burden. Watch the video: http://bit.ly/2JWHRA2

Mast cells promote small bowel cancer in a tumor stage-specific and cytokine-dependent manner

Mast cells (MCs) are tissue resident sentinels that mature and orchestrate inflammation in response to infection and allergy. While they are also frequently observed in tumors, the contribution of MCs to carcinogenesis remains unclear. Here, we show that sequential oncogenic events in gut epithelia expand different types of MCs in a temporal-, spatial-, and cytokine-dependent manner. The first wave of MCs expands focally in benign adenomatous polyps, which have elevated levels of IL-10, IL-13, and IL-33, and are rich in type-2 innate lymphoid cells (ILC2s). These vanguard MCs adhere to the transformed epithelial cells and express murine mast cell protease 2 (mMCP2; a typical mucosal MC protease) and, to a lesser extent, the connective tissue mast cell (CTMC) protease mMCP6. Persistence of MCs is strictly dependent on T cell-derived IL-10, and their loss in the absence of IL-10-expressing T cells markedly delays small bowel (SB) polyposis. MCs expand profusely in polyposis-prone mice when T cells overexpress IL-10. The frequency of polyp-associated MCs is unaltered in response to broad-spectrum antibiotics, arguing against a microbial component driving their recruitment. Intriguingly, when polyps become invasive, a second wave of mMCP5+/mMCP6+ CTMCs expands in the tumor stroma and at invasive tumor borders. Ablation of mMCP6 expression attenuates polyposis, but invasive properties of the remaining lesions remain intact. Our findings argue for a multistep process in SB carcinogenesis in which distinct MC subsets, and their elaborated proteases, guide disease progression.

Small Bowel Tumors and Polyposis: How to Approach and Manage?

Although small bowel the mainly occupies the most part of the gastrointestinal tract, small intestine tumors are rare, insidious in clinical presentation, and frequently represent a diagnostic and management challenge. Small bowel tumors are generally classified as epithelial, mesenchymal, lymphoproliferative, or metastatic. Familial adenomatous polyposis and Peutz-Jeghers syndrome are the most common inherited intestinal polyposis syndromes. Until the advent of capsule endoscopy (CE) and device-assisted enteroscopy (DAE) coupled with the advances in radiology, physicians had limited diagnostic examination for small bowel examination. CE and new radiologic imaging techniques have made it easier to detect small bowel tumors. DAE allows more diagnosis and deeper reach in small intestine. CT enteroclysis/CT enterography (CTE) provides information about adjacent organs as well as pictures of the intestinal lumen side. Compared to CTE, Magnetic resonance enteroclysis/enterography provides the advantage of soft tissue contrast and multiplane imaging without radiation exposure. Treatment and prognosis are tailored to each histological subtype of tumors.

Single Balloon Enteroscopy: A Diversity of Patients, Diagnoses, and Therapeutics - The Bellevue Hospital Experience (2008-2015)

Introduction: Single balloon enteroscopy (SBE) is a method used for evaluation of the small intestine. It is most frequently used to investigate the cause of obscure gastrointestinal (GI) bleeding, and is useful to investigate other disorders as well. In a case series of obscure overt GI bleeding, Pinto-Pais et al. demonstrated that 93.3% of patients with active bleeding underwent SBE that identified the source, and 64.3% of patients with inactive GI bleeding had a definitive bleeding source identified. The aim of our study was to evaluate the efficacy of SBE at Bellevue Hospital from its introduction at our institution in 2008 through 2015. Methods: A query of our endoscopic software was performed of SBE procedures from January 2008 through September 2015. The main inclusion criterion was patients at least 18 years of age who underwent SBE. The patient's age, past medical history, pertinent laboratory tests, procedural indications, capsule endoscopy findings, pathology results, SBE outcomes, and adverse events were collected. Results: Forty SBEs were performed during this period: twenty-nine anterograde and eleven retrograde. The average age of the patients was 51.9. Procedural indications including bleeding (18), anemia (9), retained video capsule (4), intussusception (2), mass (2), and other abnormal imaging findings (5). Nineteen procedures were successful in reaching the area in question. Diagnoses included one paraganglioma, one adenocarcinoma, one GIST, and one carcinoid. Six procedures led to treatment of AVMs with subsequent improvement in anemia. Adverse events included abdominal pain in 3 procedures. Two of these episodes resolved without intervention and the third patient was lost to follow-up. One patient had mucosal trauma and oozing. One patient had melena and a decline in hemoglobin, which resolved without intervention. One patient had a possible retroperitoneal hematoma after the procedure. Conclusion: This study outlines the diagnostic and therapeutic utility of SBE in varied clinical scenarios in the diverse patient population at Bellevue Hospital, a large tertiary care referral center in New York City. Ongoing studies would include investigating the utility of SBE in symptomatic patients without abnormal findings on imaging or laboratory studies, the use of enteroscopic localization technology to improve patient comfort, safety, and procedural efficiency, and optimizing procedural timing to determine if sensitivity and yield are enhanced.Figure: A) 73-year-old patient with obscure occult and overt GIB with video capsule endoscopy (VCE) showing blood and angioectasias. Anterograde SBE to distal jejunum showing a single non-bleeding angioectasia treated with APC. B) 78-year-old patient presented with IDA and jejunal tumor on CT. Anterograde SBE to the mid/distal jejunum showing large circumferential friable area of necrotic mucosa with overlying clot. Biopsies revealed paraganglioma, successfully managed surgically. C) 26-year-old patient with recurrent episodes of abdominal pain and intussusception. VCE demonstrated small bowel polyposis. Anterograde SBE to mid/distal jejunum demonstrated a 15mm polyp, successfully managed with saline lift-assisted polypectomy. D) 61-year-old patient with a history of colon cancer who presented with melena, IDA, and abnormal CT scan. Anterograde SBE to mid/distal jejunum revealed 5cm lesion in the third part of the duodenum, biopsies revealed invasive adenocarcinoma.

Epimorphin deletion inhibits polyposis in theApcmin/+mouse model of colon carcinogenesis via decreased myofibroblast HGF secretion

Interactions between the epithelium and surrounding mesenchyme/stroma play an important role in normal gut morphogenesis, the epithelial response to injury, and epithelial carcinogenesis. The tumor microenvironment, composed of stromal cells including myofibroblasts and immune cells, regulates tumor growth and the cancer stem cell niche. Deletion of epimorphin (Epim), a syntaxin family member expressed in myofibroblasts and macrophages, results in partial protection from colitis and from inflammation-induced colon cancer in mice. We sought to determine whether epimorphin deletion protects from polyposis in the Apcmin/+ mouse model of intestinal carcinogenesis. Epim-/- mice were crossed to Apcmin/+ mice; Apcmin/+ and Apcmin/+/Epim-/- mice were killed at 3 mo of age. Polyp numbers and sizes were quantified in small intestine and colon, and gene expression analyses for pathways relevant to epithelial carcinogenesis were performed. Primary myofibroblast cultures were isolated, and expression and secretion of selected growth factors from Apcmin/+ and Apcmin/+/Epim-/- myofibroblasts were examined by ELISA. Small bowel polyposis was significantly inhibited in Apcmin/+/Epim-/- compared with Apcmin/+ mice. Apcmin/+/Epim-/- compared with Apcmin/+ polyps and adjacent uninvolved intestinal mucosa had increased transforming growth factor-β (TGF-β) expression and signaling with increased P-Smad2/3 expression. Myofibroblasts isolated from Apcmin/+/Epim-/- vs. Apcmin/+ mice had markedly decreased hepatocyte growth factor (HGF) expression and secretion. We concluded that Epim deletion inhibits polyposis in Apcmin/+ mice, associated with increased mucosal TGF-β signaling and decreased myofibroblast HGF expression and secretion. Our data suggest that Epim deletion reduces tumorigenicity of the stromal microenvironment.

Performance of double‐balloon enteroscopy for the management of small bowel polyps in hamartomatous polyposis syndromes

Hamartomatous polyposis syndromes (HPS) are a group of rare inherited autosomal dominant disorders. Small bowel polyposis is one of the manifestations of HPS. Double-balloon enteroscopy (DBE) with polypectomy may obviate repeated small bowel surgeries for polyp intussusception, obstruction, or bleeding. The efficacy and safety of DBE-assisted polypectomy in HPS patients with clinically significant small bowel polyposis were evaluated. All HPS patients who underwent DBE from January 2007 to April 2011 were identified using a prospectively maintained database. Data on patient demographics, pre-DBE radiological studies, polyp characteristics, procedural outcomes, and complications were abstracted. Twenty-two patients underwent a total of 34 DBE procedures. Pre-DBE imaging included computed tomography enterography (n = 15), computed tomography enteroclysis (n = 5), small bowel follow-through (n = 1), and magnetic resonance enterography (n = 1). Any small bowel polyp ≥ 1 cm in size on radiological imaging was referred for DBE-assisted polypectomy. Antegrade and retrograde DBE were successful in reaching and resecting targeted polyps in 90% (18/20) and 71.4% (10/14) of procedures, respectively. The overall success rate for DBE-assisted polypectomy was 82.3% (95% confidence interval: 66.5-91.6%). The median size of resected polyps was 2 cm (range 1-5 cm) and all were hamartomas. Minor adverse events occurred in four (11.8%) procedures, including abdominal pain (n = 2), immediate post-polypectomy bleeding (n = 1), and self-limited hematochezia (n = 1). DBE-assisted polypectomy was successful in over 80% of HPS patients with an acceptable margin of safety. To the knowledge of the authors, this is one of the largest single-center studies to report on the performance and safety of DBE-assisted polypectomy in HPS patients.

Detection of the ampulla of Vater in small bowel capsule endoscopy: Experience with two different systems

The aim of this study was to determine the detection rate of the ampulla of Vater (AoV) during small bowel capsule endoscopy (SBCE) examinations and compare the two SBCE systems used in our center. SBCE procedures performed in our center from March 2005 to June 2011 were reviewed retrospectively. A single reviewer, following a detailed protocol, analyzed 30 min of each recording to identify the AoV. A total of 619 SBCE procedures were enrolled in the study, including 262 with a PillCam SB1, 148 with a PillCam SB2 and 209 with a MiroCam. AoV was identified in 59 SBCE examinations (9.5%), consisting of 28 with a PillCam SB1 (28/262, 10.7%), 13 with a PillCam SB2 (13/148, 8.8%) and 18 with a MiroCam (18/209, 8.6%) (P = 0.665). The AoV was visualized in 53.2 frames (median 12 frames, range 1-1056 frames); and the detection rate was low regardless of indication, patients' characteristics, SBCE system used or capsule transit parameters. Bile spout was associated with a higher AoV detection (P = 0.003). The persistently low AoV detection rate using two different SBCE systems underlines the weakness of non-steerable capsule endoscopy. Furthermore, if AoV detection is taken as a surrogate marker of small polyp detection, it becomes obvious both that non-steerable SBCE cannot replace a side-viewing endoscope in the evaluation of periampullary polyps in familial adenomatous polyposis and that it is an infallible method in other small bowel polyposis states.

Unexpected Small Bowel Polyposis in a Man With a Choledochal Cyst, More Than a Difficult Cannulation

Question: A 37-year-old man with a history of a choledochal cyst presented with intermittent abdominal pain and abnormal liver tests. He had undergone a cyst-jejunostomy as a child but had no other medical history except for frequent sinus infections. Magnetic resonance cholangiopancreatography revealed cystic dilatation of the intrahepatic and extrahepatic biliary tree, but the exact anatomy was unclear. Endoscopic retrograde cholangiopancreatography was performed as part of his preoperative evaluation.

Contribution of capsule endoscopy to Peutz-Jeghers syndrome management in children

BackgroundCapsule endoscopy is recommended for children with Peutz-Jeghers syndrome as young as 8 years of age. Aim of our study was to evaluate the contribution of capsule endoscopy in managing risk of further obstructive complications. MethodsA retrospective analysis of 27 children who received at least 1 capsule endoscopy was conducted. Peutz-Jeghers syndrome was diagnosed based on the presence of an STK11 gene mutation or on the association of a hamartoma with 2 of 3 criteria (family history, mucocutaneous pigmentation, small bowel polyposis). ResultsThirty-seven capsule endoscopies were performed in 27 patients. The median age at first endoscopy was 11.4 years (range, 5.4–20.9). Jejunal polyps were found in 72% and ileal polyps in 55% of capsules. The original recommendations were followed 20/30 times. Three gastroscopies, 4 colonoscopies, 7 double balloon enteroscopies and 1 intra-operative enteroscopy were performed after the capsules. These procedures revealed jejunal polyps in 9/9 cases (8/9 resected) and ileal polyps in 3/5 (all resected). One intussusception occurred 8.4 months after the capsule endoscopy and required surgical resection. ConclusionCapsule endoscopy is easily feasible in Peutz Jeghers syndrome, but the practice of systematic and repeated procedures needs to be validated prospectively.

OC-024 Spinning through the small bowel: first report of the UK (multicentre) experience of spiral enteroscopy

Introduction This decade has witnessed a revolution in small bowel (SB) endoscopy. Balloon assisted enteroscopy (double-balloon and later single-balloon) has dramatically expanded the capacity to endoscopically manage SB pathology. More recently, a novel device assisted enteroscopy named spiral enteroscopy (SE) is a promising alternative method of deep enteroscopy. SE uses a pliable plastic spiral threaded onto a flexible overtube (Spirus, Endoase Discovery SB, Spirus Medical, Massachusetts, USA). Rotational torque applied to the overtube allows the spiral thread to engage the SB. This advances the overtube and enteroscope deeper into the small bowel. Methods We report an early multicentre experience of SE since its introduction to the UK in November 2008. Results 23 procedures (12 male) were done at two tertiary referral centres. Mean age was 58 years (19–81 years). 11 procedures were done under conscious sedation while the remaining 12 were under general anaesthesia. 22 procedures were performed via the oral route; 1 procedure was done via the rectal route. Carbon dioxide was used as an insufflating gas in 13 procedures while air was used for rest. The most common indication for SE was mid-gut bleeding (n=17). Other indications included SB polyposis (n=5) and direct percutaneous endoscopic jejunostomy (DPEJ) feeding tube replacement (n=1). 22 procedures were continued to the maximal point of insertion until forward advancement of the enteroscope ceased. One oral procedure was aborted due to the presence of gastric contents despite a 14-hour fast. Mean duration of procedures was 42±12 min. In one patient, where the spiral engaged the SB throughout the procedure, pan-enteroscopy was achieved in 65 min. In the patient undergoing rectal SE, SB intubation distance was estimated to be 50 cm proximal to the ICV. Eight patients were treated with argon plasma coagulation for angioectasias and one patient had multiple polypectomies. In one patient, the overtube induced some minor submucosal bruising; the patient remained well after the procedure. No other complications ensued. The main limitation to SE was related to occasional inability of the spiral to engage the SB. In another two patients, the SE failed to reach the location of SB tattoos placed at previous DBEs. In another patient, SE failed to reach a proximal ileal polyp (subsequently reached by DBE in the same session). Conclusion The initial UK experience with SE suggests that where SB engagement readily occurs, deep SB intubation can be achieved in a relatively short time. Anecdotally, the SE also appears to provide a stable platform for therapeutic interventions. Further comparative studies would be helpful.

Video capsule endoscopy — state of the art and indications

Wireless capsule endoscopy represents a major milestone in the evolution of small bowel enteroscopy, and enables visualization of the entire small bowel in a noninvasive manner, without necessity for sedation. Indications for the test include, but are not limited to evaluation of obscure gastrointestinal bleed, Crohn disease, small bowel tumors, polyposis syndromes, and Celiac disease. Modifications of the capsule also facilitate its utilization in screening and surveillance for Barrett’s esophagus, esophageal varices, and colorectal cancer. This article is a review of the indications and recommendations regarding the role of capsule endoscopy in current clinical practice.

Enteroscopy and its Relationship to Radiological Small Bowel Imaging

The field of radiological small bowel imaging is changing rapidly, as is small bowel enteroscopy. New techniques allow the depiction of intraluminal, mural, and extraintestinal features of various small bowel disorders, such as Crohn disease, small bowel polyposis syndromes, small intestinal malignancies, and celiac disease. For patients requiring repeated small bowel imaging, modalities that do not use ionizing radiation, such as ultrasound or magnetic resonance imaging, should be considered.