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Comparison of suction capsule and endoscopic biopsy of small bowel mucosa
unaware of others who have tried our technique or that of Barkin et al. 3 and been disappointed. 4 •5 We continue to find endoscopic small bowel biopsy extremely satisfactory in our clinical work. Weare in complete agreement that proper orientation of biopsy specimens is the most important step in obtaining small bowel biopsy specimens. 6 Of course, this principle applies regardless of how the specimen is obtained. In our practice, the biopsy material is not handled in the fashion inferred by Roberts. Instead, the endoscopy assistant carefully rolls out the curled up specimen and places it mucosal side up on a piece of filter paper, which is then placed in preservative. The pathologist takes special precautions to assure that the specimen is properly oriented during fixation and sectioning. We are pleased Roberts finds, as we do, that the quality of the product obtained endoscopically is quite good. This, after all, was the point of our report. Further prospective research into the possibilities and limitations of endoscopic small bowel biopsy is clearly indicated.
ogy of the gastrointestinal tract. II. Small intestinal biopsy. Hum Pathol 1975;6:157-217.
Comparison of suction capsule and endoscopic biopsy of small bowel mucosa To the Editor: Achkar et al. l reported the results of a comparison between suction capsule and endoscopic biopsy of small bowel in 56 patients and concluded that endoscopic biopsy is the preferred way to obtain tissue from the proximal small bowel. By this technique they obtained material in 100% of attempts (vs. 81% with suction capsule), and the tissue obtained was excellent in 65% (vs. 58% with suction capsule). As we do not know of similar studies in a pediatric population where endoscopic biopsies performed with pediatric forceps give smaller specimens, we reviewed the results of a 2 years' experience in our pediatric gastrointestinal unit (September 1984-September 1986). A total of 313 small bowel biopsies were carried out in this period. 137 children underwent biopsy with a pediatric Watson suction biopsy capsule for suspected celiac disease at various stages (malabsorption, or after gluten-free diet, or after gluten challenge) according to the criteria of the European Society of Pediatric Gastroenterology and Nutrition (ESPGAN) for the diagnosis of celiac disease. 2 Most children received an intravenous premedication with diazepam (0.2 mg/kg) but this was avoided in infants. In the same period 167 biopsies were performed with an Olympus GIF P3 pediatric endoscope and a pediatric forceps (Olympus FB 21K) with an open cup diameter of 1.7 mm. Gastroduodenoscopies were performed in 66 cases for suspected celiac disease at various stages and in 110 cases for other upper gastrointestinal tract disease (peptic ulcer, esophagitis, gastritis, or duodenitis). All children received oral premedication with 1 to 2 mg of diazepam and tetracaine. Results are summarized in Table 1. Of 137 biopsies performed with the Watson capsule, 26
Edgar Achkar, MD William D. Carey, MD Department of Gastroenterology The Cleveland Clinic Foundation Cleveland, Ohio
REFERENCES 1. Achkar E, Carey WD, Petras R, Sivak MV, Revta R. Comparison of suction capsule and endoscopic biopsy of small bowel mucosa. Gastrointest Endosc 1986;32:278-81. 2. Korn ER, Foroozan P. Endoscopic biopsies of normal duodenal mucosa. Gastrointest Endosc 1974;21:51-4. 3. Barkin JS, Schonfelt W, Thomsen S, Mantan HD, Rogers AI. Enteroscopy and small bowel biopsy-an improved technique for the diagnosis of small bowel disease. Gastrointest Endosc 1985;31:215-7. 4. Scott BB, Jenkins D. Endoscopic small intestinal biopsy. Gastrointest Endosc 1981;27:162-7. 5. Gillberg, Ahren C. Coeliac disease diagnosed by means of duodenoscopy and endoscopic duodenal biopsy. Scand J Gastroenterol 1977;12:911-6. 6. Perera DR, Weinstein WM, Rubin CEo Symposium on pathol-
Table 1. Comparison of the adequacy of small bowel biopsy specimens obtained with pediatric forceps during endoscopy or with Watson pediatric suction capsule for suspected celiac disease and other diseases· Technique and indications
Specimen quality
Specimen not obtained
No. Adequate
Not adequate
Pediatric forceps Suspected CD
66
58 (87%)
8 (12%)
OD Watson capsule
110
96 (87%)
14 (12%)
Suspected CD
137
111 (81%)
10 (n)
313
264 (84%)
32
Total
o
{NR 1 (12%) VA 6 (76%) N 1 (12%)
rR3130%)
VA 5 (50%) N 1 (10%) D 1 (10%)
16 (12%)
r
7143
%) VA 3 (18%) N 6 (37%)
16
CD, celiac disease; OD, other diagnosis (gastritis, esophagitis, duodenitis, peptic ulcer); NR, not repeated; VA, villous atrophy; N, normal small bowel mucosa; D, duodenitis. a
VOLUME 33, NO.3, 1987
265
(19%) were unsuccessful, 16 (12%) because the pylorus could not be passed. In 7 of these (43%) the diagnosis was made by other means; in 9 suction biopsy was successfully repeated after a short course of domperidone: in 6 (36%) the pathologist found normal small bowel mucosa, while in 3 (18%) villous atrophy. In 10 (7%) cases the suction biopsy specimens were judged inadequate at histological examination. When reattempted, 5 (50%) showed villous atrophy, 1 (10%) normal mucosa, 1 (10%) duodenitis; in 3 cases the parents refused permission for a second attempt. Of the 66 biopsies performed at endoscopy with pediatric forceps in children with suspected celiac disease, specimens were obtained in all cases (100%), but in 8 (12%) they were technically inadequate. The same percentage of success was obtained for biopsies taken for various other diseases. In one ofthese (12%) the biopsy was not repeated, while in the remaining 7 a second attempt was made: 6 (75%) showed villous atrophy and 1 (12%) a normal mucosa at histological examination. In conclusion, our results show that failure is higher with the suction (19%) than with the endoscopic technique (12%) even when using a pediatric forceps, a finding similar to that reported in 40 adults by Mee et al.,3 who had compared the suction capsule with the pediatric forceps and with the adult size forceps. Their results are comparable to those of Achkar et al. l and of Scott and Jenkins,4 who used an adult size forceps on 93 adult patients and noted inadequate specimens in 13% of patients. When a mucosal specimen is obtained, the histological diagnosis can be made in almost an equal percentage of cases (87% with the endoscopic forceps and 81 % with the suction capsule) as shown by Gillberg and Ahren 5 on 19 adults. When we analyzed the histological diagnosis made at the second attempt in the 18 cases in which the first biopsy specimens were technically inadequate, we noted that 50% and 75%, depending on the technique, were villous atrophy, suggesting greater friability of the atrophic mucosa that might be more easily damaged during the procedure. When a second attempt was made in the 16 cases where the pylorus has not been passed, in 9 (37%) cases normal mucosa was found, while only in 3 (18%) villous atrophy. Our impression is that the pylorus is more difficult to pass in a normal child or in a celiac patient on a gluten-free diet. Moreover, the majority of children in whom the pylorus could not be passed at first attempt were older than 3 years. Therefore, our present policy is to use the suction biopsy in younger children and the endoscopic technique in the older ones, especially when on a gluten-free diet.
bowel biopsy for malabsorption: comparison of the diagnostic adequacy of endoscopic forceps and capsule biopsy specimens. Br Med J 1985;291:769-76. 4. Scott BB, Jenkins D. Endoscopic small intestinal biopsy. Gastrointest Endosc 1981;27:162-7. 5. Gillberg R, Ahren C. Coeliac disease diagnosed by means of duodenoscopy and endoscopic duodenal biopsy. Scand J GastroenteroI1977;12:911-6.
Ablation of a gastric neurogenic tumor with endoscopic laser therapy To the Editor: The initial symptoms of neurogenic tumors (neurinomas), the most common of the nonepithelial tumors in the upper gastrointestinal tract, are usually late. I • 2 In view of the possible associated complications, especially obstruction, surgical treatment is considered the treatment of choice. 3 • 4 For a very old female patient with gastrointestinal bleeding from a gastric neurinoma, we employed an alternative form of therapy, namely, endoscopic laser ablation. An 84-year-old female patient was admitted to the hospital with tarry stools for 2 weeks. She had a history of coronary heart disease with congestive heart failure, hypertension, and insulin-dependent diabetes mellitus. The physical examination revealed marked edema of the lower legs, cyanosis of the lips, and mild dyspnea at rest. The hemoglobin was 9 gldl, and blood sugar 406 mg/dl. At the gastroscopic examination, we observed on the lesser curvature in the upper third of the stomach a 4-cm mushroom-like tumor projecting into the lumen (Fig. 1). The mucosa was smooth and nonadherent, while the apex of the tumor revealed central ulceration with a visible vessel and blood coagulum. Grossly, this tumor presented the typical aspect of a submucosa gastric lesion. From the buttonhole (scalping) biopsy material, the histological diagnosis of neurinoma was established. By the barium meal examination, a relatively smooth, oval mass with a central deposit of barium was observed. Because of the poor general condition of the patient and her rejection of operative intervention, we decided in favor of endoscopic laser removal of the tumor. In the initial session, the surface of the tumor was
Giuseppina Oderda, MD Nicoletta Ansaldi, MD Istituto di Discipline Pediatriche Sezione di Gastroenterologia Universita di Torino Torino, Italy
REFERENCES 1. Achkar E, Carey WD, Petras R, Sivak MV, Revta R. Comparison of suction capsule and endoscopic biopsy of small bowel mucosa. Gastrointest Endosc 1986;32:278-81. 2. Meewisse GW. Diagnostic criteria in coeliac disease. Acta Paediatr Scand 1970;59:461-5. 3. Mee AS, Burke M, Vallon AG, Newman J, Cotton PB. Small
266
Figure 1. Typical endoscopic aspect of a submucosal gastric tumor.
GASTROINTESTINAL ENDOSCOPY
ogy of the gastrointestinal tract. II. Small intestinal biopsy. Hum Pathol 1975;6:157-217.
Comparison of suction capsule and endoscopic biopsy of small bowel mucosa To the Editor: Achkar et al. l reported the results of a comparison between suction capsule and endoscopic biopsy of small bowel in 56 patients and concluded that endoscopic biopsy is the preferred way to obtain tissue from the proximal small bowel. By this technique they obtained material in 100% of attempts (vs. 81% with suction capsule), and the tissue obtained was excellent in 65% (vs. 58% with suction capsule). As we do not know of similar studies in a pediatric population where endoscopic biopsies performed with pediatric forceps give smaller specimens, we reviewed the results of a 2 years' experience in our pediatric gastrointestinal unit (September 1984-September 1986). A total of 313 small bowel biopsies were carried out in this period. 137 children underwent biopsy with a pediatric Watson suction biopsy capsule for suspected celiac disease at various stages (malabsorption, or after gluten-free diet, or after gluten challenge) according to the criteria of the European Society of Pediatric Gastroenterology and Nutrition (ESPGAN) for the diagnosis of celiac disease. 2 Most children received an intravenous premedication with diazepam (0.2 mg/kg) but this was avoided in infants. In the same period 167 biopsies were performed with an Olympus GIF P3 pediatric endoscope and a pediatric forceps (Olympus FB 21K) with an open cup diameter of 1.7 mm. Gastroduodenoscopies were performed in 66 cases for suspected celiac disease at various stages and in 110 cases for other upper gastrointestinal tract disease (peptic ulcer, esophagitis, gastritis, or duodenitis). All children received oral premedication with 1 to 2 mg of diazepam and tetracaine. Results are summarized in Table 1. Of 137 biopsies performed with the Watson capsule, 26
Edgar Achkar, MD William D. Carey, MD Department of Gastroenterology The Cleveland Clinic Foundation Cleveland, Ohio
REFERENCES 1. Achkar E, Carey WD, Petras R, Sivak MV, Revta R. Comparison of suction capsule and endoscopic biopsy of small bowel mucosa. Gastrointest Endosc 1986;32:278-81. 2. Korn ER, Foroozan P. Endoscopic biopsies of normal duodenal mucosa. Gastrointest Endosc 1974;21:51-4. 3. Barkin JS, Schonfelt W, Thomsen S, Mantan HD, Rogers AI. Enteroscopy and small bowel biopsy-an improved technique for the diagnosis of small bowel disease. Gastrointest Endosc 1985;31:215-7. 4. Scott BB, Jenkins D. Endoscopic small intestinal biopsy. Gastrointest Endosc 1981;27:162-7. 5. Gillberg, Ahren C. Coeliac disease diagnosed by means of duodenoscopy and endoscopic duodenal biopsy. Scand J Gastroenterol 1977;12:911-6. 6. Perera DR, Weinstein WM, Rubin CEo Symposium on pathol-
Table 1. Comparison of the adequacy of small bowel biopsy specimens obtained with pediatric forceps during endoscopy or with Watson pediatric suction capsule for suspected celiac disease and other diseases· Technique and indications
Specimen quality
Specimen not obtained
No. Adequate
Not adequate
Pediatric forceps Suspected CD
66
58 (87%)
8 (12%)
OD Watson capsule
110
96 (87%)
14 (12%)
Suspected CD
137
111 (81%)
10 (n)
313
264 (84%)
32
Total
o
{NR 1 (12%) VA 6 (76%) N 1 (12%)
rR3130%)
VA 5 (50%) N 1 (10%) D 1 (10%)
16 (12%)
r
7143
%) VA 3 (18%) N 6 (37%)
16
CD, celiac disease; OD, other diagnosis (gastritis, esophagitis, duodenitis, peptic ulcer); NR, not repeated; VA, villous atrophy; N, normal small bowel mucosa; D, duodenitis. a
VOLUME 33, NO.3, 1987
265
(19%) were unsuccessful, 16 (12%) because the pylorus could not be passed. In 7 of these (43%) the diagnosis was made by other means; in 9 suction biopsy was successfully repeated after a short course of domperidone: in 6 (36%) the pathologist found normal small bowel mucosa, while in 3 (18%) villous atrophy. In 10 (7%) cases the suction biopsy specimens were judged inadequate at histological examination. When reattempted, 5 (50%) showed villous atrophy, 1 (10%) normal mucosa, 1 (10%) duodenitis; in 3 cases the parents refused permission for a second attempt. Of the 66 biopsies performed at endoscopy with pediatric forceps in children with suspected celiac disease, specimens were obtained in all cases (100%), but in 8 (12%) they were technically inadequate. The same percentage of success was obtained for biopsies taken for various other diseases. In one ofthese (12%) the biopsy was not repeated, while in the remaining 7 a second attempt was made: 6 (75%) showed villous atrophy and 1 (12%) a normal mucosa at histological examination. In conclusion, our results show that failure is higher with the suction (19%) than with the endoscopic technique (12%) even when using a pediatric forceps, a finding similar to that reported in 40 adults by Mee et al.,3 who had compared the suction capsule with the pediatric forceps and with the adult size forceps. Their results are comparable to those of Achkar et al. l and of Scott and Jenkins,4 who used an adult size forceps on 93 adult patients and noted inadequate specimens in 13% of patients. When a mucosal specimen is obtained, the histological diagnosis can be made in almost an equal percentage of cases (87% with the endoscopic forceps and 81 % with the suction capsule) as shown by Gillberg and Ahren 5 on 19 adults. When we analyzed the histological diagnosis made at the second attempt in the 18 cases in which the first biopsy specimens were technically inadequate, we noted that 50% and 75%, depending on the technique, were villous atrophy, suggesting greater friability of the atrophic mucosa that might be more easily damaged during the procedure. When a second attempt was made in the 16 cases where the pylorus has not been passed, in 9 (37%) cases normal mucosa was found, while only in 3 (18%) villous atrophy. Our impression is that the pylorus is more difficult to pass in a normal child or in a celiac patient on a gluten-free diet. Moreover, the majority of children in whom the pylorus could not be passed at first attempt were older than 3 years. Therefore, our present policy is to use the suction biopsy in younger children and the endoscopic technique in the older ones, especially when on a gluten-free diet.
bowel biopsy for malabsorption: comparison of the diagnostic adequacy of endoscopic forceps and capsule biopsy specimens. Br Med J 1985;291:769-76. 4. Scott BB, Jenkins D. Endoscopic small intestinal biopsy. Gastrointest Endosc 1981;27:162-7. 5. Gillberg R, Ahren C. Coeliac disease diagnosed by means of duodenoscopy and endoscopic duodenal biopsy. Scand J GastroenteroI1977;12:911-6.
Ablation of a gastric neurogenic tumor with endoscopic laser therapy To the Editor: The initial symptoms of neurogenic tumors (neurinomas), the most common of the nonepithelial tumors in the upper gastrointestinal tract, are usually late. I • 2 In view of the possible associated complications, especially obstruction, surgical treatment is considered the treatment of choice. 3 • 4 For a very old female patient with gastrointestinal bleeding from a gastric neurinoma, we employed an alternative form of therapy, namely, endoscopic laser ablation. An 84-year-old female patient was admitted to the hospital with tarry stools for 2 weeks. She had a history of coronary heart disease with congestive heart failure, hypertension, and insulin-dependent diabetes mellitus. The physical examination revealed marked edema of the lower legs, cyanosis of the lips, and mild dyspnea at rest. The hemoglobin was 9 gldl, and blood sugar 406 mg/dl. At the gastroscopic examination, we observed on the lesser curvature in the upper third of the stomach a 4-cm mushroom-like tumor projecting into the lumen (Fig. 1). The mucosa was smooth and nonadherent, while the apex of the tumor revealed central ulceration with a visible vessel and blood coagulum. Grossly, this tumor presented the typical aspect of a submucosa gastric lesion. From the buttonhole (scalping) biopsy material, the histological diagnosis of neurinoma was established. By the barium meal examination, a relatively smooth, oval mass with a central deposit of barium was observed. Because of the poor general condition of the patient and her rejection of operative intervention, we decided in favor of endoscopic laser removal of the tumor. In the initial session, the surface of the tumor was
Giuseppina Oderda, MD Nicoletta Ansaldi, MD Istituto di Discipline Pediatriche Sezione di Gastroenterologia Universita di Torino Torino, Italy
REFERENCES 1. Achkar E, Carey WD, Petras R, Sivak MV, Revta R. Comparison of suction capsule and endoscopic biopsy of small bowel mucosa. Gastrointest Endosc 1986;32:278-81. 2. Meewisse GW. Diagnostic criteria in coeliac disease. Acta Paediatr Scand 1970;59:461-5. 3. Mee AS, Burke M, Vallon AG, Newman J, Cotton PB. Small
266
Figure 1. Typical endoscopic aspect of a submucosal gastric tumor.
GASTROINTESTINAL ENDOSCOPY