Suspected Small Bowel Disease Research Articles

Optimal Diagnostic Approaches for Patients with Suspected Small Bowel Disease.

While the domain of gastrointestinal endoscopy has made great strides over the last several decades, endoscopic assessment of the small bowel continues to be challenging. Recently, with the development of new technology including video capsule endoscopy, device-assisted enteroscopy, and computed tomography/magnetic resonance enterography, a more thorough investigation of the small bowel is possible. In this article, we review the systematic approach for patients with suspected small bowel disease based on these advanced endoscopic and imaging systems.

Antegrade Is More Effective Than Retrograde Enteroscopy for Evaluation and Management of Suspected Small-Bowel Disease

Antegrade and retrograde enteroscopy are useful for evaluating the proximal and distal small bowel, respectively. We compared the diagnostic yield, therapeutic yield, and complications of antegrade and retrograde enteroscopy. We performed a retrospective review of a prospectively maintained database of patients who underwent small-bowel enteroscopy at our institution from January 2008 to August 2009. All enteroscopies were performed using single-balloon enteroscopy (SBE), double-balloon enteroscopy (DBE), or spiral enteroscopy (SE). A total of 250 enteroscopies were performed; 182 were antegrade (91 SBE, 52 DBE, and 39 SE) and 68 were retrograde (23 SBE, 37 DBE, and 8 SE). The mean age of the patients was 61.5 ± 15.8 years. The most common indication for small-bowel endoscopy was obscure gastrointestinal bleeding (n = 83). The diagnostic yield was significantly higher for antegrade than retrograde enteroscopy (63.7% vs 39.7%; P < .001). Antegrade procedures were of shorter duration than retrograde enteroscopy (44.3 ± 22.0 vs 58.9 ± 29.7 min; P < .001), and the mean depth of maximal insertion was significantly greater with antegrade endoscopy (231.8 ± 122.1 vs 103.4 ± 102.8 cm; P < .001). The therapeutic yield also was significantly higher for anterograde enteroscopy than retrograde enteroscopy (55.5% vs 44.1%; P < .001). There were no significant differences in complications. Antegrade enteroscopy appears to provide a higher diagnostic and therapeutic yield than retrograde enteroscopy in patients with suspected small-bowel disease.

S1020 Self-Administered Inhaled Methoxyflurane Significantly Improves Patient Comfort During Nasoduodenal Intubation for Computed Tomography Enteroclysis (CTE) for Suspected Small Bowel Disease: A Randomized, Double-Blinded, Placebo Controlled Trial

S1020 Self-Administered Inhaled Methoxyflurane Significantly Improves Patient Comfort During Nasoduodenal Intubation for Computed Tomography Enteroclysis (CTE) for Suspected Small Bowel Disease: A Randomized, Double-Blinded, Placebo Controlled Trial

W1599: Single Balloon Enteroscopy System Might Be More Efficient Among Three Available Enteroscopy Systems for Evaluation and Management of Suspected Small Bowel Disease

W1599: Single Balloon Enteroscopy System Might Be More Efficient Among Three Available Enteroscopy Systems for Evaluation and Management of Suspected Small Bowel Disease

Diagnostic Yield and Therapeutic Impact of Single Balloon Enteroscopy; A Series of 60 Patients with Suspected Small Bowel Disease

Introduction: Non surgical management of small intestinal diseases is difficult due to lack of proper instruments to access the long redundant bowel loops. Single balloon enteroscopy (SBE) is novel method of push and pull enteroscopy which allows deep intubation of intestine. Aim: Single-center prospective study conducted from February 2007 to October 2007, to evaluate the clinical utility of the prototype SBE system. Methods: Subjects with suspected small bowel disease who required deep enteroscopy were enrolled. The Olympus XSIF-Q260Y enteroscope [200 cm length,9.2 mm outer diameter (OD), and 2.8 mm working channel] was coupled with a 132 cm long,13.2 mm OD single use silicon overtube, which has a balloon at the distal end. Balloon is operated with Olympus balloon control unit (MAJ 1440). The tip of the enteroscope has a broad bending capability due to its extreme flexibility allowing anchorage to the small bowel thus facilitating deep intubation. Depth of insertion was determined by carefully recording length of the scope inserted during each pull and push maneuver. Fluoroscopy was utilized intermittently. Enteroscopy was done under monitored anesthesia care (Midazolam, Propofol). All patients underwent antegrade enteroscopic examination, 10 underwent both antegrade and retrograde procedures, with tattooing during the initial procedure to confirm a total small-bowel examination. Results: A total of 60 subjects (36M /24F, mean age 39.83 ± 14.66 Years) were studied. Indications for SBE included obscure GI bleeding(18),chronic abdominal pain with abnormal imaging studies like Barium series, CTscan etc (21), malabsorption Syndrome (11), Polyposis syndromes (9) and Foreign body (1). Mean procedure time was 63 ± 18 min. The mean depth of insertion was 260 ± 60 cms beyond ligament of Treitz. Pan-enteroscopy was possible in 5 out of 10 cases. Enteroscopic findings were arteriovenous malformations [AVMs] (7), ulcers (15), polyps (6), diffuse enteritis (2), mass lesion (3) and effacement of jejunal folds (3). Histological diagnosis included adenocarcinoma (3), Crohn's disease (4), Tuberculosis (2), Strongyloidosis (2), Giardiasis (1), Amyloidosis (1), Celiac Sprue (4), Tropical sprue(1), Hamartomatous polyps (4) and non specific ulcers(9). Diagnostic yield in cases of obscure G I bleed, chronic abdominal pain and malabsorption syndrome were 77%, 61% and 63% respectively. Therapeutic interventions included Argon plasma coagulation of bleeding ulcers and AVMs (12), Polypectomy (3) and foreign body removal (1). No complications were encountered. Conclusion-The Olympus single balloon enteroscope was well-tolerated and led to a high diagnostic and therapeutic yield in cases of small bowel disorders.

Double-Balloon Enteroscopy (DBE) and Capsule Endoscopy (CE) Have a Comparable Diagnostic Yield in Patients with Suspected Small Bowel Disease: A Meta-Analysis

Background: Endoscopic small bowel imaging has been significantly advanced by the introduction of both CE and DBE. It is not known for certain which modality has the best diagnostic yield. Aim: To compare the diagnostic yield of CE with that of DBE in patients with suspected small bowel disease using meta-analysis. Methods: A recursive literature search of studies comparing the yield of CE to other modalities in patients with suspected small bowel disease was performed. Data on the diagnostic yield in CE and DBE were extracted, pooled and analyzed using RevMan 4.2.9 software; heterogeneity was tested by the chi2 method and a p-value of <0.1 was considered significant heterogeneity. Weighted incremental yield (IYW) (yield of CE - yield of DBE) of CE over DBE and 95% confidence intervals (CI) for the pooled data was calculated using a fixed effect model (FEM) for analyses without and a random effect model (REM) for analyses with significant heterogeneity. Results: Eleven studies compared the diagnostic yield of CE with DBE. The pooled overall yield for CE and DBE was 60% (n = 393) and 57% (n = 356), respectively (IYW = 3%; CI -3-10%; P = 0.34; FEM). Eight studies reported the yield of vascular findings on CE and DBE. The pooled yield for CE and DBE for vascular findings was 24% (n = 313) and 25% (n = 306), respectively (IYW = −3%; CI -14-8%; P = 0.62; REM). Seven studies reported the yield of inflammatory findings (erosions, ulcers and strictures) on CE and DBE. The pooled yield for CE and DBE was 18% (n = 285) and 16% (n = 278), respectively (IYW = 0%; CI -6-6%; P = 0.93; FEM). Seven studies reported the yield of polyps/tumors on CE and DBE. The pooled yield for CE and DBE was 7% (n = 285) and 12% (n = 278), respectively (IYW = −3%; CI -8-2%; P = 0.25; FEM). Conclusions: In patients with suspected small bowel disease, DBE had a comparable yield to CE for the diagnosis of small bowel pathology. Because the capsule is non-invasive, these results would suggest that CE is the initial diagnostic test of choice in most patients with suspected small bowel disease. In those patients with a positive finding on CE or a high suspicion of a small bowel lesion despite a negative CE, DBE would be indicated for further evaluation due to its diagnostic and therapeutic capabilities.

A Prospective Trial Comparing Double-Balloon Endoscopy with Barium Contrast Series and CT in Patients with Suspected Small Bowel Disease

Background and Aims: Double-balloon endoscopy (DBE) is a novel procedure for diagnosis of small bowel pathology, but little is known about the importance of DBE compared with other imaging modalities for diagnosis of small bowel disease. The aim of this investigation was to prospectively compare DBE findings with findings of two standard conventional screening tests (small bowel follow-through [SBFT] and contrast-enhanced computed tomography [CT]) in patients with suspected small bowel disease. Subjects and Methods: One hundred ten consecutive patients (63 males, 47 females; mean age, 54.1 ± 1.7 years age, range, 9-85 years) underwent DBE, and the majority (73/110) did so for obscure gastrointestinal bleeding. Within 1 month before DBE, 91 patients underwent both SBFT and CT, 7 patients underwent only SBFT and 12 patients underwent only CT. The number of positive DBE findings was compared with the number of positive SBFT and/or CT findings. Statistical significance was calculated with McNemar's χ2 statistic. Results: SBFT findings were positive in 31 of 98 (31.6%) patients. CT findings were positive in 28 of 103 (27.2%) patients. SBFT or CT findings were positive in 36 of 110 (32.7%) patients; DBE findings were positive in 69 of 110 (62.7%) patients (p < 0.001). Some lesions (n = 32) examined in detail by DBE had been detected in previous screening tests, and others (n = 37) were detected for the first time by DBE. Previous screening tests had failed to detect 53.6% of those lesions, many of which were microscopic lesions such as angiodysplasia, erosions and small ulcers (Table 1). Conclusions: DBE appears to be particularly useful for diagnosing microscopic lesions in the mucosa; such lesions are difficult to detect by conventional screening. Table 1Findings by DBE and two standard conventional screening tests (SBFT, CT) Findings DBE SBFT, CT Angiodysplasia 7 0 Erosion 5 1 Fistula 1 1 Foreign body 1 1 Mass 22 13 Ulcer 34 16 Total 70 32 DBE: double-balloon endoscopy, SBFT: small bowel follow-through, CT: computed tomography Open table in a new tab DBE: double-balloon endoscopy, SBFT: small bowel follow-through, CT: computed tomography

Capsule Endoscopy in Patients With Malignant Melanoma

Although small bowel (SB) involvement is found at postmortem in 50-60% of melanoma patients, diagnosis is only made during life in 10% of cases. This study reports the findings of capsule endoscopy (CE) in melanoma patients referred for investigation of suspected SB involvement. Eight men and five women with known or previous melanoma were referred for CE between December 2003 and September 2006. The indications were gastrointestinal bleeding (three), anemia (six), positive fecal occult blood test (one), abnormal imaging (two), and abdominal pain (one). CE showed SB metastases in five patients and excluded SB involvement in eight. All patients had previous investigations with either endoscopy, push enteroscopy, SB follow-through, CT scan, and/or PET scan. CE showed new lesions not detected by other investigation modalities. CE also ruled out SB metastases when other tests were nondiagnostic. All five patients with SB metastases detected underwent surgical resection. At follow-up after CE of a mean 8.4 months (1-23 months) and 4.9 months (0.25-10 months) after surgery, five patients had died, including three of those who had undergone resection of SB metastases. Seven patients were still alive, including two who had SB surgery. One patient was lost to follow-up. CE may detect the presence and extent of SB metastases in patients with melanoma more reliably than conventional investigations. It should be considered in the workup of melanoma patients with suspected SB disease.

Outcome of Double-Balloon Enteroscopy After Capsule Endoscopy in Patients with Suspected Small-Bowel Disease

Capsule endoscopy (CE) is a purely diagnostic method with no capability to sample tissue or perform therapy. Double-balloon enteroscopy (DBE), offers the potential for complete small-bowel examination and treatment of previously-inaccessible lesions. Aims: The study assessed technical and clinical outcomes of DBE in patients (pts) previously submitted to CE and with suspected small-bowel disease. Methods: Between January and November 2005,44 pts. were enrolled (30 men; mean age 58 yrs) who were suffering from obscure bleeding (28),polyposis syndromes (10), refractory celiac disease (2),or suspected Crohn's disease (4). The double-balloon enteroscope (Fujinon EN-450P5/20) was used. The choice of first approach with DBE (oral or anal) was made on the basis of CE findings. DBE was performed under sedoanalgesic medication,and the small-bowel examination progressed until either a lesion was discovered or scope progression was blocked.If the suspected lesion had not been reached,the small-bowel mucosa was marked with a tattoo at the most distal site reached during oral DBE or at the most proximal site during transanal DBE,and a second procedure was performed through the opposite route the following day. Fluoroscopy was used whenever endoscope progression was blocked during insertion. Results: 30 out of 44 pts.had CE findings located only in the jejunum: AVMs (6), mass (6), ulcers (6), polyps (6), hyperemic mucosa (6). 8 out of 44 had CE findings located only in the ileum: AVMs (2), polyps (4), mass (2). 6 pts. had CE findings located both in the jejunun and in the ileum: AVMs (4), polyps (2). A total of 62 DBE procedures were carried out in the 44 pts: 30 (48%) through the oral route alone, 8 (13%) through the anal route alone, and 24 (39%) through both routes. DBE through the anal approach was not possible in two pts. On an average 220 ± 85 cm (60-350) small bowel were visualized using the oral route and 115 ± 80 cm (35-270) using the anal route. The mean duration of examinations was 79 ± 23 min (30-135) through the oral route, and 88 ± 21 min (50-130) through the anal route. No complications were recorded. In comparison with the CE findings, the prior diagnosis was confirmed by DBE in 77% of pts; a new diagnosis was made in 14%; a suspected diagnosis was excluded in 9%. The DBE findings played a role in subsequent treatment in 32 (73%) of 44 pts. Endoscopic treatments were carried out in 14 (44%); 14 (44%) pts. were referred for surgery and medical treatment was started in 4 (12%). Conclusions: DBE is a useful tool for the further characterization and management of small-bowel lesions suspected at capsule examination. Prior CE can help to decide which approach should be attempted first with DBE.

Double-Balloon Enteroscopy: Indications, Diagnostic Yield, and Complications in a Series of 275 Patients with Suspected Small-Bowel Disease

Until recently, only the proximal small bowel was accessible for diagnostic and therapeutic endoscopy. This paper describes experience in the first 275 patients examined and treated with the new method of double-balloon enteroscopy (DBE), which is expected to make full-length enteroscopy possible. Between November 2003 and May 2005, double-balloon enteroscopy was conducted in 275 consecutive patients presenting at two tertiary referral hospitals. The characteristics of the patients, indications for the procedures, procedural parameters, and diagnostic yield are described here. All conventional treatment options were available. The tolerability of the procedure was assessed in a small subset of the patients. After the procedure, the patients were monitored in a recovery room for at least 2h. They were discharged afterwards, provided there were no signs of complications or complaints. The main indication for DBE was suspected small-bowel bleeding (n=168), and the lesions responsible for the bleeding were found in 123 patients (73 %) and treated in 61 (55 %). In patients with refractory celiac disease (n=25), DBE revealed a high proportion (six patients, 23 %) of enteropathy-associated T-cell lymphomas that had not been suspected on other tests. Further DBE indications were surveillance and treatment of hereditary polyposis syndromes (n=20); and suspected Crohn's disease, which was diagnosed with DBE in four of 13 patients (30 %). No relevant pathology was found in 24 % of the patients. Panenteroscopy was successfully performed in 26 of 62 patients (42 %) in whom it was attempted, in either one or two sessions. The average duration of the procedures was 90 min (range 30 - 180 min, SD 42), and the average insertion length was 270 cm (range 60 - 600 cm, SD 104). Patients' tolerance of the procedure was excellent. Severe complications were recognized in three cases (1 %), all involving pancreatitis. This large pilot series shows that DBE is a well-tolerated and safe new endoscopic technique with a high diagnostic yield in selected patients.

M2A Wireless Capsule Endoscopy Versus Enteroclysis; A Prospective Study in 68 Patients with Suspected Small Bowel Disease

M2A Wireless Capsule Endoscopy Versus Enteroclysis; A Prospective Study in 68 Patients with Suspected Small Bowel Disease Periklis Apostolopoulos, Eleftheria Giannakoulopoulou, Ioannis S. Papanikolaou, Georgios Alexandrakis, X. Papacharalampous, Chrissostomos Kalantzis, Peter Gabriel, Nikolaos Kalantzis Background and Study Aims: To compare the diagnostic yield of wireless capsule endoscopy (WCE) and enteroclysis (EC) in suspected small bowel (SB) disease. Patients and Methods: Sixty-eight patients (31 men, 37 women; mean age:59+/ 18 years, range:17-78 years) with suspected SB disease (obscure GI bleeding: 47pts, unexplained chronic diarrhea: 15pts, miscellaneous: 6pts) were prospectively studied. EC followed by WCE was performed in all patients; gastroenterologists were blinded to the results of EC at the time of interpretation of the WCE video. Both WCE and radiological findings were characterized as specific and non-specific, if the patients signs and symptoms could be or couldn’t be sufficiently attributed to them, respectively. Chi-square test and Fisher exact test were used for statistical analysis. Results: Abnormal findings were documented in 14/68pts using EC and in 53/68pts using WCE (20.6% vs. 77.9% respectively, p=0.000). For the diagnostic yield of WCE vs. enteroclysis in demonstrating specific abnormal findings, WCE was also more effective (47% vs. 14.7%, p=0.0000). Moreover, WCE is more effective in revealing abnormal findings in obscure GI bleeding (76.6% vs. 10.6% of enteroclysis, p=0.0000). Specific findings in this group were 42.5% and 6.4% respectively (p=0.0000). In 15 pts evaluated for unexplained chronic diarrhoea, abnormal findings were detected in 10/15 (66.6%) byWCE and in 4/15(26.6%) by EC (p<0.05). It should be pointed out that, WCE was able to diagnose Crohn’s disease of the SB, undetected by conventional diagnostic methods in 9/68 pts (5pts were evaluated for obscure GI bleeding and 4pts for unexplained chronic diarrhoea). Conclusions: The present study suggests that in certain patient groups with suspected SB disorders, WCE has a superior diagnostic yield compared to EC. Its usefulness is undoubted for the evaluation of patients with obscure GI bleeding and chronic unexplained diarrhoea. WCE complements the traditional work-up in patients with suspected SB disease, holding the promise that fewer patients with SB disorders will remain undiagnosed, especially as it concerns SB Crohn’s disease. *M1704 A Novel Autofluorlesence Imaging Videoendoscopy System for Diagnosis of Esophago-Gastric Cancers Noriya Uedo, Hiroyasu Iishi, Masaharu Tatsuta, Yoshiyuki Hukushima, Koji Higashino, Ryu Ishihara, Hiroyuki Narahara An autofluorescence endoscopy sytem produces real-time pseudo-color images that specify lesions including gastrointestinal malignancies and it has possibility to detect early-stage lesions that were difficult to observe with conventional white light endoscopy. We have investigated an effectiveness of light-induced fluorescence endoscopy system (LIFE) on screening for superficial esophageal squamous cell carcinomas (SESCC) and on diagnosis of early gastric adenocarcinoma (EGA). However, LIFE used fiber-optic scope in its system, so its image quality and handleability were not enough for general clinical usage. Therefore we are developing novel autofluorlesence imaging videoendoscopy system (AFI, manufactured by Olympus Optical Co., Ltd.). In this study, we evaluated its feasibility for clinical application. AFI equipped two CCDs; one for white-light observation and another for autofluorescence observation, on the tip of the scope and they could be easily switched by small push button on the scope handle. AFI compose real-time images from pseudocolors of autofluorescence (excitation: 395475 nm, detection: 490-625 nm), red reflection (R’: 600-620) and green reflection (G’: 540-560) by sequentialmethod in order to represent clear image profiles and to distinguish reduction of autofluorescence by tumor from that by hemoglobin. Assessing the image resolutions of AFI and LIFE-GI by OMC resolution chart (lines/mm at 5 mm distance), AFI has higher resolution than LIFE-GI at both whight light (16 and six) and autofluorescence (seven and five) observation. We studied five patients with SESCC and 12 patients with EGA by AFI. For the esophagus, SESCC were observed as well contrasted magenta colored areas in green normal mucosa (Figure). We found a small secondary primary lesion in a patient with SESCCat autofluoresence observation. For the stomach, EGA exist in atrophic mucosa were observed as magenta colored areas in bright green background mucosa, while EGA exist in fundic mucosa were observed as green areas in magenta background mucosa. Non-specific inflammations or patchy atrophic changes often contaminate detection of tumor or assessment of tumor extension. Image quality of AFI videoendoscopy system at both white-light and autofluorescence observations was feasible for evaluating its clinical usefulness for SESCC. The system will be tuned-up to improve specificity for diagnosis of EGA.