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Capillary refilling sign demonstrated by capsule endoscopy
Capillary refilling sign demonstrated by capsule endoscopy Patients with occult GI bleeding frequently are referred for evaluation of the small intestine as a potential source of bleeding after a negative upper endoscopy and colonoscopy. Capsule endoscopy is a novel technique for examination of the small intestine of patients with chronic GI bleeding. It increasingly is being used as a first-line diagnostic modality in the evaluation of chronic GI bleeding because of patient preference owing to the absence of discomfort and the high sensitivity compared with push enteroscopy in the diagnosis of small bowel lesions.1-3 Although the primary purpose of capsule endoscopy is the evaluation of suspected small bowel bleeding, experience with push enteroscopy has demonstrated that a substantial proportion of patients presumed to have such bleeding actually have lesions within the stomach that have been overlooked at EGD.4 A patient is described in whom capsule endoscopy demonstrated capillary blanching followed by refilling of red lesions in the gastric antrum, previously mistaken as hemorrhagic gastritis, indicating the presence of an underlying vascular, instead of inflammatory, disorder. Case report. A 72-year-old man with iron deficiency anemia was referred for localization by capsule endoscopy of a source of GI bleeding. The medical history included cholecystectomy, appendectomy, and resection of the terminal ileum after a gunshot wound to the abdomen. He recovered well from the ileal surgery except for diarrhea caused by a combination of bile salt malabsorption and lactose intolerance (8-12 bowel movements per day). There was no history of bowel obstruction, and he was not taking aspirin or other non-steroidal anti-inflammatory drug. During evaluation at the referring community hospital, the Hb level had decreased from 13.4 g/dL to 9.5 g/dL (normal: 14-18 g/dL). His iron stores were low (serum iron: 29 mcg/dL [range: 40-155 mcg/dL]; iron saturation: 7%). Despite 6 months of iron supplementation therapy, the Hb level did not increase. A diagnosis of hemorrhagic gastritis had been made by upper endoscopy. Antral biopsy specimens revealed chronic gastritis with intestinal metaplasia; Helicobacter pylori was not identified. Duodenal biopsy specimens were normal. Colonoscopy to the cecum was unremarkable except for internal hemorrhoids, diverticulosis, and a small tubular adenoma. CT of the abdomen demonstrated chronic splenic vein thrombosis with venous collaterals in the left upper quadrant and minimal dilatation of the proximal small bowel. Contrast radiography of the small bowel by enteroclysis was normal.
Reprint requests: G.S. Raju, MD, Center for Endoscopic Research, Training, and Innovation (CERTAIN), 4.106 McCullough Bldg., 301 University Blvd., University of Texas Medical Branch, Galveston, TX 77555-0764. Copyright Ó 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 PII: S0016-5107(03)02236-3 936
GASTROINTESTINAL ENDOSCOPY
Figure 1. Capsule endoscopic view of vascular telangiectasias in stomach. The patient was referred for capsule endoscopy at which tiny blood clots were observed in the stomach, along with extensive red patches in the body and antrum (Fig. 1). As the capsule pressed against the walls of the antrum, blanching of the red lesions, followed quickly by refilling, was seen (Fig. 2). Finally, eruption of the capillaries and fresh capillary bleeding were noted as the capsule was propelled through the pylorus with repetitive antral contractions (Fig. 3). Fresh blood clots were observed intermittently throughout the length of the small intestine. Upper endoscopy demonstrated the classic findings of gastric antral vascular ectasia (GAVE, ‘‘watermelon stomach’’), confirming the capsule endoscopic diagnosis. Other findings included 3 small esophageal varices and a few telangiectatic lesions at the gastroesophageal junction, and the cardia of the stomach and in the duodenal bulb. By using a 7F multipolar probe (power 16-20 watts), the antral lesions were coagulated in two sessions. The patient was treated with esomeprazole (40 mg twice a day), and supplemental iron was continued. After endoscopic treatment, the Hb increased to 12 g/dL (14-18 g/dL). At 4 months’ follow-up, there was no recurrence of the anemia. Discussion. Gastric antral vascular ectasia is one of the causes of severe and persistent iron deficiency anemia. Jabbari et al.5 described the endoscopic findings in 3 patients: longitudinal folds arranged radially around the pylorus, each containing a cluster of visible vessels, and the aggregates resembling the stripes on a watermelon seen end on. Despite increased awareness of GAVE as a distinct pathologic entity that can be diagnosed endoscopically by its classic appearance, it sometimes is mislabeled as gastritis, and patients with this condition are mistakenly referred for enteroscopy to evaluate the small bowel for a potential source of bleeding, as in the case presented.4,6,7 Misdiagnosis of GAVE could be because of a lack of knowledge or, more often, difficulty in differentiating the erythema of gastritis from vascular ectasia by conventional endoscopy. Demonstration of capillary refilling is the sine qua non for the diagnosis of cutaneous VOLUME 58, NO. 6, 2003
Brief Reports
G Raju, K Morris, S Boening, et al.
Figure 3. Capsule endoscopic view showing fresh capillary bleeding.
DISCLOSURE
Figure 2. A, Capsule endoscopic view showing blanching of antral vascular ectasias in response to pressure exerted by dome of capsule endoscope. B, Refilling of antral vascular ectasias as capsule endoscope bounced back. Pylorus is at the 7-o’clock position.
telangiectasia. The design of the capsule endoscope, with illumination and imaging systems placed away from the clear dome of the tip, is well suited to appreciate dynamic changes in microvessels, with the application of pressure as the capsule presses against the walls of the gut. Demonstration of capillary blanching and refilling confirmed the vascular nature of the red antral lesions in our patient, and capsule endoscopy, therefore, provided the diagnosis of GAVE. Although it is believed that demonstration of capillary blanching and refilling endoscopy is a true finding, the possibility that this was artifactual cannot be excluded; examination of a series of patients with GAVE would be needed to confirm or refute this observation. This is the first reported demonstration of the classic physical sign of capillary refilling with an endoscope in the GI tract. This case also illustrates that capsule endoscopy provides important diagnostic information from the upper GI tract, as well as the small bowel. VOLUME 58, NO. 6, 2003
None of the authors work for GIVEN Imaging, receive support from the company, or have financial interest in the company. Gottumukkala S. Raju, MD Keith Morris, MD Sharon Boening, BSN Deborah Carpenter, RN Guillermo Gomez, MD Department of Medicine and Surgery Center for Endoscopic Research, Training, and Innovation (CERTAIN) University of Texas Medical Branch at Galveston, Galveston, Texas
REFERENCES 1. Lewis BS, Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: results of a pilot study. Gastrointest Endosc 2002;56:349-53. 2. Costamagna G, Shah SK, Riccioni ME, Foschia F, Mutignani M, Perri V, et al. A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease. Gastroenterology 2002;123:999-1005. 3. Ell C, Remke S, May A, Helou L, Henrich R, Mayer G. The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding. Endoscopy 2002;34:685-9. 4. Chak A, Koehler MK, Sundaram SN, Cooper GS, Canto MI, Sivak MV. Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings. Gastrointest Endosc 1998;47:18-22. 5. Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Goresky CA. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology 1984;87:1165-70. 6. Gouldesbrough DR, Pell AC. Gastric antral vascular ectasia. A problem of recognition and diagnosis. Gut 1991;32:954-5. 7. Merrett MN, Machet D, Ring J, Desmond PV, Martin CJ. Watermelon stomach: an unusual cause of chronic gastrointestinal blood loss. Aust N Z J Surg 1991;61:393-6. GASTROINTESTINAL ENDOSCOPY
937
Reprint requests: G.S. Raju, MD, Center for Endoscopic Research, Training, and Innovation (CERTAIN), 4.106 McCullough Bldg., 301 University Blvd., University of Texas Medical Branch, Galveston, TX 77555-0764. Copyright Ó 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 PII: S0016-5107(03)02236-3 936
GASTROINTESTINAL ENDOSCOPY
Figure 1. Capsule endoscopic view of vascular telangiectasias in stomach. The patient was referred for capsule endoscopy at which tiny blood clots were observed in the stomach, along with extensive red patches in the body and antrum (Fig. 1). As the capsule pressed against the walls of the antrum, blanching of the red lesions, followed quickly by refilling, was seen (Fig. 2). Finally, eruption of the capillaries and fresh capillary bleeding were noted as the capsule was propelled through the pylorus with repetitive antral contractions (Fig. 3). Fresh blood clots were observed intermittently throughout the length of the small intestine. Upper endoscopy demonstrated the classic findings of gastric antral vascular ectasia (GAVE, ‘‘watermelon stomach’’), confirming the capsule endoscopic diagnosis. Other findings included 3 small esophageal varices and a few telangiectatic lesions at the gastroesophageal junction, and the cardia of the stomach and in the duodenal bulb. By using a 7F multipolar probe (power 16-20 watts), the antral lesions were coagulated in two sessions. The patient was treated with esomeprazole (40 mg twice a day), and supplemental iron was continued. After endoscopic treatment, the Hb increased to 12 g/dL (14-18 g/dL). At 4 months’ follow-up, there was no recurrence of the anemia. Discussion. Gastric antral vascular ectasia is one of the causes of severe and persistent iron deficiency anemia. Jabbari et al.5 described the endoscopic findings in 3 patients: longitudinal folds arranged radially around the pylorus, each containing a cluster of visible vessels, and the aggregates resembling the stripes on a watermelon seen end on. Despite increased awareness of GAVE as a distinct pathologic entity that can be diagnosed endoscopically by its classic appearance, it sometimes is mislabeled as gastritis, and patients with this condition are mistakenly referred for enteroscopy to evaluate the small bowel for a potential source of bleeding, as in the case presented.4,6,7 Misdiagnosis of GAVE could be because of a lack of knowledge or, more often, difficulty in differentiating the erythema of gastritis from vascular ectasia by conventional endoscopy. Demonstration of capillary refilling is the sine qua non for the diagnosis of cutaneous VOLUME 58, NO. 6, 2003
Brief Reports
G Raju, K Morris, S Boening, et al.
Figure 3. Capsule endoscopic view showing fresh capillary bleeding.
DISCLOSURE
Figure 2. A, Capsule endoscopic view showing blanching of antral vascular ectasias in response to pressure exerted by dome of capsule endoscope. B, Refilling of antral vascular ectasias as capsule endoscope bounced back. Pylorus is at the 7-o’clock position.
telangiectasia. The design of the capsule endoscope, with illumination and imaging systems placed away from the clear dome of the tip, is well suited to appreciate dynamic changes in microvessels, with the application of pressure as the capsule presses against the walls of the gut. Demonstration of capillary blanching and refilling confirmed the vascular nature of the red antral lesions in our patient, and capsule endoscopy, therefore, provided the diagnosis of GAVE. Although it is believed that demonstration of capillary blanching and refilling endoscopy is a true finding, the possibility that this was artifactual cannot be excluded; examination of a series of patients with GAVE would be needed to confirm or refute this observation. This is the first reported demonstration of the classic physical sign of capillary refilling with an endoscope in the GI tract. This case also illustrates that capsule endoscopy provides important diagnostic information from the upper GI tract, as well as the small bowel. VOLUME 58, NO. 6, 2003
None of the authors work for GIVEN Imaging, receive support from the company, or have financial interest in the company. Gottumukkala S. Raju, MD Keith Morris, MD Sharon Boening, BSN Deborah Carpenter, RN Guillermo Gomez, MD Department of Medicine and Surgery Center for Endoscopic Research, Training, and Innovation (CERTAIN) University of Texas Medical Branch at Galveston, Galveston, Texas
REFERENCES 1. Lewis BS, Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: results of a pilot study. Gastrointest Endosc 2002;56:349-53. 2. Costamagna G, Shah SK, Riccioni ME, Foschia F, Mutignani M, Perri V, et al. A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease. Gastroenterology 2002;123:999-1005. 3. Ell C, Remke S, May A, Helou L, Henrich R, Mayer G. The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding. Endoscopy 2002;34:685-9. 4. Chak A, Koehler MK, Sundaram SN, Cooper GS, Canto MI, Sivak MV. Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings. Gastrointest Endosc 1998;47:18-22. 5. Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Goresky CA. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology 1984;87:1165-70. 6. Gouldesbrough DR, Pell AC. Gastric antral vascular ectasia. A problem of recognition and diagnosis. Gut 1991;32:954-5. 7. Merrett MN, Machet D, Ring J, Desmond PV, Martin CJ. Watermelon stomach: an unusual cause of chronic gastrointestinal blood loss. Aust N Z J Surg 1991;61:393-6. GASTROINTESTINAL ENDOSCOPY
937