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Association of Regional Transit Abnormalities Identified On Capsule Endoscopy with Underlying Pathology
Abstracts
M1308 Early Experience with CT Enterography (CTE) in Patients Before Video Capsule Endoscopy (VCE) Daniel S. Mishkin, Brian C. Lucey Background: With the advent of VCE, we are able to evaluate the mucosa of the entire small bowel (SB) in a non-invasive manner. However, capsule retention may occur in 1-5% of studies, depending on the indication. A small bowel follow through (SBFT) has traditionally been the radiographic study of choice for examining the SB lumen and to identify a stricture that may lead to capsule retention. CTE using 64 row detector CT and VoLumenÒ, a negative oral contrast agent, offers an imaging alternative to the SBFT that circumvents some of the difficulties associated with interpreting the SBFT series. Methods: We performed a retrospective analysis of all patients at our institution that have undergone a CTE before undergoing a VCE, to evaluate its clinical usefulness. All patients for a VCE are booked through one Gastroenterologist. The data was evaluated to assess if CTE can both predict potential capsule retention and identify SB pathology when compared to VCE. Results: A total of 20 CTE studies have been performed as a preVCE assessment. Thirteen patients have undergone both tests, while 4 are awaiting VCE. The remaining 3 cases had significant intraluminal changes that altered management and no VCE was performed.Of the 13 cases with both studies, one CTE documented a transition point and proximal dilatation of the SB without a complete obstruction. The SBFT did not identify a transition point and was interpreted as negative. The patient still underwent a capsule study and required surgical removal of a retained capsule at the identified sites. Three VCE studies documented SB neoplasms that were not visualized on CTE. Three patients had vascular ectasias seen on VCE with normal CTE, and one case questioned SB mucosal thickening with a normal VCE. There were no significant extraluminal findings in any patient to date. Conclusion: CTE provides an alternative imaging modality to visualize the small intestine in a non-invasive manner. In our preliminary evaluation it has identified pre-VCE patients at high risk of capsule retention and may become a screening test to identify small bowel patency prior to VCE. The ability of CTE to identify mucosal defects is limited, as it did not identify vascular ectasias or the few cases of a suspected SB neoplasm seen on VCE. Importantly, a few patients did not need to undergo a VCE following CTE as it identified a significant abnormality that explained their clinical status. The data to date is limited. With the advancement of our ongoing prospective trial, we will be able to better assess whether CTE pre-VCE avoids a non-natural passage of the capsule and helps make the correct diagnosis.
M1310 A Prospective Randomized Multicenter Study of Preparation for Capsule Endoscopy Jun Hwan Wi, Jeong Seop Moon, Yong Sik Kim, Ki Nam Shim, Kyung Jo Kim, Young Ho Kim, Tae Il Kim, Jae Hyuk Do, Ji Kon Ryu, Soo Hyun Park, Cheol Hee Park, in Seok Lee, Jin Oh Kim, Hoon Jai Chun, Myung Gyu Choi Background/Aims: Capsule endoscopy opened the new era of small bowel disease. Studies have found that capsule endoscopy has a higher diagnostic yield than push enteroscopy and barium contrast small bowel series. But in some cases, visualization of small bowel mucosa was restricted because of intestinal contents, bubbles, and foods. Some studies of capsule endoscopy prepared the small bowel with purgative drugs but it is not determined which preparation makes better image and higher diagnostic yield. The aim of this study is to evaluate the efficacy of different bowel preparations and to compare diagnostic yield of preparation drugs. Patients and Methods: 125 patients were randomized into three groups. Patients in group A (n Z 38) fasted for 12 H before ingestion the capsule, patients in group B (n Z 44) were asked to drink 45 ml sodium phosphate with water the afternoon and the evening before the procedure. They were asked to drink at least 2 liters clear water. Patients in group C (n Z 43) ingested 2 liters of a polyethylene glycol/ electrolyte lavage solution the evening before the procedure. The image quality was classified as excellent, good, fair, and poor according to an objective score system. Results: There was no difference between the three groups in terms of age, sex and indications of capsule endoscopy. Overall cleansing of small bowel was excellent or good in 47.2% of patients in group A, 77.3% in group B, and 47.6% in group C (p ! 0.05). The diagnosis was established in 12 patients in group A (33%), 27 patients in group B (61.4%) and 16 patients in group C (37.2%) (p ! 0.05). Conclusions: Bowel preparation with sodium phosphate for capsule endoscopy improved the visibility of small bowel mucosa and diagnostic yield compared to overnight 12 H fasting. Also in comparison with polyethylene glycol/electrolyte lavage solution, sodium phosphate showed a tendency to improve the visibility (p Z 0.078) and diagnostic yield (p Z 0.07). Key words: capsule endoscopy, sodium phosphate, polyethylene glycol/electrolyte lavage solution
M1311 Success Rate of Direct Percutaneous Endoscopic Jejunostomy (DPEJ) in Obese Patients Scott H. Mackenzie, Derrick Haslem, Kristen Hilden, Kristen Thomas, James A. Disario, John Fang M1309 Association of Regional Transit Abnormalities Identified On Capsule Endoscopy with Underlying Pathology Steve Kucera, Rami Abbass, Gerard Isenberg, Richard Wong, Amitabh Chak, Michael V. Sivak Introduction: Capsule endoscopy (CE) has emerged as a valuable tool for identifying small bowel pathology. Small bowel regional transit abnormalities (RTAs) are claimed to be associated with pathology; however, there are no published studies available to demonstrate this association. This preliminary study evaluates whether the observation of a RTA on CE indicates underlying small bowel pathology. Methods: A prospective blinded review of 107 CE studies using Rapid Software for Pilcam SB (Given Diagnostic Imaging System) was performed between October 2003 and October 2004. RTAs were defined as slow movement of the capsule for more that 60 continuous minutes with or without obvious mucosal abnormalities. A separate reader blinded to the original report reviewed capsule exams specifically looking for RTAs. RTAs were then correlated with any underlying pathology. A 13-month chart review was completed following the initial capsule study to establish if small bowel pathology (bleeding, masses, strictures, ulcerations) was identified by CE and/or other testing (surgery, push enteroscopy, repeat CE). Two-way contingency table analysis using Fischer’s Exact Test was executed to determine whether identification of RTAs predicted underlying pathology in the small bowel. Results: Of the 107 CE studies reviewed, RTAs were observed in 14 studies (13%). Underlying pathology (bleeding, masses, strictures, ulcerations) was identified in 3 of the 14 (21%) cases of RTAs. Pathology was identified in 12 of 93 cases (13%) without an RTA. Statistical evaluation yielded an odds ratio of 1.85 for identifying underlying pathology when an RTA was observed. This relationship was not statistically significant (p-value Z 0.41). Conclusion: Identification of regional transit abnormalities in the small bowel on capsule endoscopy did not result in a significant increase in identification of underlying small bowel pathology. These preliminary results contradict current reports in the literature that small bowel RTAs do correlate with pathology. Further data collection is necessary to validate these preliminary findings.
AB168 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
Background: DPEJ is increasingly utilized as a method for obtaining jejunal enteral access. Reported procedural success rates ranges from 72-88% and the most cited reason of unsuccessful placement is poor transillumination, which may be related to obesity. Whether obesity affects failure and complication rates has not been previously described. Aims: To compare the success rate and adverse events (AEs) associated with DPEJ placement in overweight and obese patients compared with normal or underweight patients defined by body mass index (BMI). Methods: Retrospective database analysis identified 76 DPEJ placements which had full data available for analysis (of 80 total attempts) at the University of Utah between February 2000 and September 2005. The primary endpoint was DPEJ placement success in overweight/obese patients (BMI R 25) vs. normal or underweight patients (BMI ! 25). Secondary endpoints included procedure time and AE’s. Underweight defined as BMI ! 18.5., overweight 25-29.9, and obese R30. Major AEs were defined as requiring hospitalization, urgent endoscopy or surgery. Results: 80 DPEJs were placed in 75 patients. Of these, 65 (81%) succeeded and 15 (19%) failed. Success rates were 23/24 (96%) for underweight, 25/31 (81%) for normal BMI, 8/11 (73%) for overweight, and 6/10 (60%) for obese persons (OR 4.7, CI 0.87-2.44, p Z 0.03). The mean procedure duration was 46 minutes (G24) for patients with BMI R 25 and 50 minutes (G19) for those with BMI ! 25 (p Z NS). AEs occurred in 21/55 (38%) of patients with BMI ! 25 and occurred in 9/21 (43%) with BMI R 25 (p Z .64). Four of the 5 severe AEs (1 sepsis, 1 necrotizing fascitis, 1 jejunal obstruction, 2 jejunal volvulus) occurred in patients with a BMI R 25 (p Z 0.07). Conclusions: DPEJ placement in overweight and obese patients is feasible, but the procedural success is less frequent and major AEs are more frequent than in persons with normal or decreased BMI. BMI is an easily assessed factor for DPEJ procedural success and complication rates. Success vs. Failure Rates Weight Under Normal Overweight Obese
BMI
Number
Success Rate
!18.5 18.5-24.9 25-29.9 R30
23/24 25/31 8/11 6/10
96% 81% 73% 60%
p-value !0.05 for BMI!25 vs. R25 !0.05 for BMI!25 vs. R30
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M1308 Early Experience with CT Enterography (CTE) in Patients Before Video Capsule Endoscopy (VCE) Daniel S. Mishkin, Brian C. Lucey Background: With the advent of VCE, we are able to evaluate the mucosa of the entire small bowel (SB) in a non-invasive manner. However, capsule retention may occur in 1-5% of studies, depending on the indication. A small bowel follow through (SBFT) has traditionally been the radiographic study of choice for examining the SB lumen and to identify a stricture that may lead to capsule retention. CTE using 64 row detector CT and VoLumenÒ, a negative oral contrast agent, offers an imaging alternative to the SBFT that circumvents some of the difficulties associated with interpreting the SBFT series. Methods: We performed a retrospective analysis of all patients at our institution that have undergone a CTE before undergoing a VCE, to evaluate its clinical usefulness. All patients for a VCE are booked through one Gastroenterologist. The data was evaluated to assess if CTE can both predict potential capsule retention and identify SB pathology when compared to VCE. Results: A total of 20 CTE studies have been performed as a preVCE assessment. Thirteen patients have undergone both tests, while 4 are awaiting VCE. The remaining 3 cases had significant intraluminal changes that altered management and no VCE was performed.Of the 13 cases with both studies, one CTE documented a transition point and proximal dilatation of the SB without a complete obstruction. The SBFT did not identify a transition point and was interpreted as negative. The patient still underwent a capsule study and required surgical removal of a retained capsule at the identified sites. Three VCE studies documented SB neoplasms that were not visualized on CTE. Three patients had vascular ectasias seen on VCE with normal CTE, and one case questioned SB mucosal thickening with a normal VCE. There were no significant extraluminal findings in any patient to date. Conclusion: CTE provides an alternative imaging modality to visualize the small intestine in a non-invasive manner. In our preliminary evaluation it has identified pre-VCE patients at high risk of capsule retention and may become a screening test to identify small bowel patency prior to VCE. The ability of CTE to identify mucosal defects is limited, as it did not identify vascular ectasias or the few cases of a suspected SB neoplasm seen on VCE. Importantly, a few patients did not need to undergo a VCE following CTE as it identified a significant abnormality that explained their clinical status. The data to date is limited. With the advancement of our ongoing prospective trial, we will be able to better assess whether CTE pre-VCE avoids a non-natural passage of the capsule and helps make the correct diagnosis.
M1310 A Prospective Randomized Multicenter Study of Preparation for Capsule Endoscopy Jun Hwan Wi, Jeong Seop Moon, Yong Sik Kim, Ki Nam Shim, Kyung Jo Kim, Young Ho Kim, Tae Il Kim, Jae Hyuk Do, Ji Kon Ryu, Soo Hyun Park, Cheol Hee Park, in Seok Lee, Jin Oh Kim, Hoon Jai Chun, Myung Gyu Choi Background/Aims: Capsule endoscopy opened the new era of small bowel disease. Studies have found that capsule endoscopy has a higher diagnostic yield than push enteroscopy and barium contrast small bowel series. But in some cases, visualization of small bowel mucosa was restricted because of intestinal contents, bubbles, and foods. Some studies of capsule endoscopy prepared the small bowel with purgative drugs but it is not determined which preparation makes better image and higher diagnostic yield. The aim of this study is to evaluate the efficacy of different bowel preparations and to compare diagnostic yield of preparation drugs. Patients and Methods: 125 patients were randomized into three groups. Patients in group A (n Z 38) fasted for 12 H before ingestion the capsule, patients in group B (n Z 44) were asked to drink 45 ml sodium phosphate with water the afternoon and the evening before the procedure. They were asked to drink at least 2 liters clear water. Patients in group C (n Z 43) ingested 2 liters of a polyethylene glycol/ electrolyte lavage solution the evening before the procedure. The image quality was classified as excellent, good, fair, and poor according to an objective score system. Results: There was no difference between the three groups in terms of age, sex and indications of capsule endoscopy. Overall cleansing of small bowel was excellent or good in 47.2% of patients in group A, 77.3% in group B, and 47.6% in group C (p ! 0.05). The diagnosis was established in 12 patients in group A (33%), 27 patients in group B (61.4%) and 16 patients in group C (37.2%) (p ! 0.05). Conclusions: Bowel preparation with sodium phosphate for capsule endoscopy improved the visibility of small bowel mucosa and diagnostic yield compared to overnight 12 H fasting. Also in comparison with polyethylene glycol/electrolyte lavage solution, sodium phosphate showed a tendency to improve the visibility (p Z 0.078) and diagnostic yield (p Z 0.07). Key words: capsule endoscopy, sodium phosphate, polyethylene glycol/electrolyte lavage solution
M1311 Success Rate of Direct Percutaneous Endoscopic Jejunostomy (DPEJ) in Obese Patients Scott H. Mackenzie, Derrick Haslem, Kristen Hilden, Kristen Thomas, James A. Disario, John Fang M1309 Association of Regional Transit Abnormalities Identified On Capsule Endoscopy with Underlying Pathology Steve Kucera, Rami Abbass, Gerard Isenberg, Richard Wong, Amitabh Chak, Michael V. Sivak Introduction: Capsule endoscopy (CE) has emerged as a valuable tool for identifying small bowel pathology. Small bowel regional transit abnormalities (RTAs) are claimed to be associated with pathology; however, there are no published studies available to demonstrate this association. This preliminary study evaluates whether the observation of a RTA on CE indicates underlying small bowel pathology. Methods: A prospective blinded review of 107 CE studies using Rapid Software for Pilcam SB (Given Diagnostic Imaging System) was performed between October 2003 and October 2004. RTAs were defined as slow movement of the capsule for more that 60 continuous minutes with or without obvious mucosal abnormalities. A separate reader blinded to the original report reviewed capsule exams specifically looking for RTAs. RTAs were then correlated with any underlying pathology. A 13-month chart review was completed following the initial capsule study to establish if small bowel pathology (bleeding, masses, strictures, ulcerations) was identified by CE and/or other testing (surgery, push enteroscopy, repeat CE). Two-way contingency table analysis using Fischer’s Exact Test was executed to determine whether identification of RTAs predicted underlying pathology in the small bowel. Results: Of the 107 CE studies reviewed, RTAs were observed in 14 studies (13%). Underlying pathology (bleeding, masses, strictures, ulcerations) was identified in 3 of the 14 (21%) cases of RTAs. Pathology was identified in 12 of 93 cases (13%) without an RTA. Statistical evaluation yielded an odds ratio of 1.85 for identifying underlying pathology when an RTA was observed. This relationship was not statistically significant (p-value Z 0.41). Conclusion: Identification of regional transit abnormalities in the small bowel on capsule endoscopy did not result in a significant increase in identification of underlying small bowel pathology. These preliminary results contradict current reports in the literature that small bowel RTAs do correlate with pathology. Further data collection is necessary to validate these preliminary findings.
AB168 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
Background: DPEJ is increasingly utilized as a method for obtaining jejunal enteral access. Reported procedural success rates ranges from 72-88% and the most cited reason of unsuccessful placement is poor transillumination, which may be related to obesity. Whether obesity affects failure and complication rates has not been previously described. Aims: To compare the success rate and adverse events (AEs) associated with DPEJ placement in overweight and obese patients compared with normal or underweight patients defined by body mass index (BMI). Methods: Retrospective database analysis identified 76 DPEJ placements which had full data available for analysis (of 80 total attempts) at the University of Utah between February 2000 and September 2005. The primary endpoint was DPEJ placement success in overweight/obese patients (BMI R 25) vs. normal or underweight patients (BMI ! 25). Secondary endpoints included procedure time and AE’s. Underweight defined as BMI ! 18.5., overweight 25-29.9, and obese R30. Major AEs were defined as requiring hospitalization, urgent endoscopy or surgery. Results: 80 DPEJs were placed in 75 patients. Of these, 65 (81%) succeeded and 15 (19%) failed. Success rates were 23/24 (96%) for underweight, 25/31 (81%) for normal BMI, 8/11 (73%) for overweight, and 6/10 (60%) for obese persons (OR 4.7, CI 0.87-2.44, p Z 0.03). The mean procedure duration was 46 minutes (G24) for patients with BMI R 25 and 50 minutes (G19) for those with BMI ! 25 (p Z NS). AEs occurred in 21/55 (38%) of patients with BMI ! 25 and occurred in 9/21 (43%) with BMI R 25 (p Z .64). Four of the 5 severe AEs (1 sepsis, 1 necrotizing fascitis, 1 jejunal obstruction, 2 jejunal volvulus) occurred in patients with a BMI R 25 (p Z 0.07). Conclusions: DPEJ placement in overweight and obese patients is feasible, but the procedural success is less frequent and major AEs are more frequent than in persons with normal or decreased BMI. BMI is an easily assessed factor for DPEJ procedural success and complication rates. Success vs. Failure Rates Weight Under Normal Overweight Obese
BMI
Number
Success Rate
!18.5 18.5-24.9 25-29.9 R30
23/24 25/31 8/11 6/10
96% 81% 73% 60%
p-value !0.05 for BMI!25 vs. R25 !0.05 for BMI!25 vs. R30
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