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Capsule Endoscopy for Obscure GI Bleeding Yields a High Incidence of Significant Treatable Lesions Within Reach of Standard Upper Endoscopy
Abstracts
M1321 The World Around the Gastric Polyp Riaz Dor, Patrick DuBois, Kalpesh Besherdas, Steven Mann, Niall van Someren Background: Gastric epithelial polyps are an infrequent endoscopic finding with a prevalence of about 2%. These can be divided into largely 3 histological types; hyperplastic (60%), fundic gland polyps (25%), and adenomas (10%). Hyperplastic and, to a lesser degree, adenomatous polyps have been associated with chronic gastritis, gastric atrophy and intestinal metaplasia in the surrounding gastric mucosa. Whereas this association does not exist with gastric fundal polyps. Often the focus at endoscopy is on the polyp and not the surrounding tissues. The aim of this study was to investigate this relationship further. Aims & Methods: Prospective analysis of 1097 patients referred to the endoscopy unit for a variety of indications revealed a total 32 polyps. At endoscopy the polyp was snared and sent for histological analysis along with 6 biopsies from the mucosa surrounding the polyp. Results: 32 patients (20 male, 12 female) with polyps were found. Age range 38-94 years. Polyp size 3-50 mm. Frequency of polyps: 24 (75%) hyperplastic, 6 (22%) fundal gland, 1 (3%) adenomatous, 1 (3%) inflammatory. Polyps were more commonly seen in those over 50 years of age. Males were more likely to have hyperplastic polyps. The mucosa surrounding hyperplastic polyp was associated with chronic active gastritis in 92% of cases (p ! 0.05) ,with gastric atrophy in 15% (p ! 0.05) and intestinal metaplasia in 6%. No association was found between the size or site of polyp. However, as expected, the presence of Helicobacter pylori was a risk factor for gastric atrophy and intestinal metaplasia. Conclusion: The presence of apparent gastric polyps is an important finding and, as this study shows, may herald potential mucosal abnormalities in the surrounding areas, thus making biopsies of such polyps as well as the surrounding mucosa an important management policy.
M1322 Capsule Endoscopy (CE) in Evaluation of Patients with Celiac Disease (CD) Elena Dubcenco, Khursheed N. Jeejeebhoy, Rima Petroniene, Ralph C. Warren, Clifford A. Ottaway, Geoffrey W. Gardiner, Cathy J. Streutker, Jeffrey P. Baker Aim: To establish the accuracy of CE in diagnosing villous atrophy (VA) using small bowel (SB) histology as a ‘‘gold standard’’. To evaluate the ability of CE to correctly interpret mucosal changes in CD patients after introduction of a gluten free diet (GFD). Methods: Participants (CD and control group) had serology, upper endoscopy, SB biopsy and CE. Standard endoscopic criteria in identifying VA were applied to CE. An investigator blinded to other tests’ findings randomly reviewed CE images. Patients’ identification details were coded. Histological confirmation of CD (Marsh’s III-IV type) was considered diagnostic of CD. All tests were repeated in CD group to assess patients’ response after 6 months of the GFD. A dedicated dietitian assessed patients’ baseline gluten intake followed by compliance to the GFD. The investigator blinded to other tests’ findings reviewed and compared CE images taken before with the images taken after introduction of the GFD. Results: Evaluated 41 (29 CD, 12 healthy controls). Mean age-45.3 yr, SDZ15.94 (range 17-77). 1 patient’s data (CD group) was excluded from the analysis (Marsh’s I-II type). In the diagnosis of VA, CE yielded a sensitivity/a specificity of 89.3%/91.7%, positive/negative predictive values of 96.2%/78.6%. Importantly, CE revealed 3 CD patients with ulcerative jejunitis. 15 CD patients were re-evaluated after 6 months of the GFD. 12/15 improved histologically and clinically. 3/15 did not experience any changes in their condition. 1 of the 3 was found completely and 1 partially non-complaint to the GFD. When compared to histology CE correctly interpreted positive/negative mucosal changes after introduction of the GFD in 12/15 patients (80%). Conclusions: CE may be suggested for further work up of histologically confirmed CD patients. With its ability to visualize the entire SB and high accuracy in identifying VA, CE could provide a non-invasive way of evaluating CD patients, monitoring the response to the GFD as well as lifelong screening for CD related complications such as ulcerative jejunitis or malignancy.
www.mosby.com/gie
M1323 Double-Balloon Endoscopy for Diagnoses of Small Bowel Tumors Akihito Ehara, Shu Tanaka, Atsushi Tatsuguchi, Katya Gudis, Keigo Mitsui, Tsuyoshi Kobayashi, Yoshihisa Sekita, Tsuguhiko Seo, Masaoki Yonezawa, Yoshiaki Shibata, Kazuhiro Nagata, Shunji Fujimori, Teruyuki Kishida, Choitsu Sakamoto Backgrounds and Aims: Small bowel tumors accounts for only 1-2% of all gastrointestinal tumors. In addition, small bowel tumors often go undiagnosed, given the limitations of traditional endoscopy, and radiological procedures such as enteroclysis and CT scan, in visualizing the small intestine. Furthermore, the relative inaccessibility of the small intestine precludes easy retrieval of samples for histopathological analysis without resorting to surgery. Yamamoto et al. have developed a new endoscopy system, called double-balloon endoscopy (DBES), which enables endoscopic scrutiny and treatment of the entire small bowel. The aim of this study was to evaluate the value and potential of this endoscopic system in the diagnosis of small bowel tumors. Patients and Methods: The DBES (EN-450P5/20, EN-450T5/20, Fujinon, Fuji Photo Optical Co., Ltd., Saitama, Japan) was used to perform 90 enteroscopies in 65 patients between June 2003 and November 2004 at Nippon Medical School Hospital. The system was assessed on the basis of diagnostic yields and complications. Results: Small bowel tumors were detected in 8 (12%) of 65 patients. Forceps biopsy specimens were obtained through DBES and histopathological examination was possible in all 8 patients. Of the 8 patients, 5 were males and 3 females, with ages ranging from 42 to 82 years (average, 65 years). Chief complaints were gastrointestinal bleeding in 5 patients, anemia in 2 patients and diarrhea in 1 patient. The tumors were located in the jejunum in 3 patients, and in the ileum in 5 patients. Tumors were diagnosed histopathologically as: gastrointestinal tumor (GIST) in 5 (67%) patients, malignant lymphoma in 2 (25%) patients and adenocarcinoma in 1 (12%) patient. Of the 5 patients with GIST, 4 had celiotomy and 1 had celiotomy, with subsequent adjuvant chemotherapy. Of the 2 patients with malignant lymphoma, one patient had chemotherapy; the other, celiotomy, with subsequent adjuvant chemotherapy. One patient with adenocarcinoma had laparoscopic enterectomy. We encountered no complications during DBES procedures. Conclusions: DBES allows through examination of the entire small bowel, with a 100% success rate of histopathlogical assessment endoscopically. The procedure is safe and of great diagnostic value and aids in the appropriate selection of therapeutic modalities.
M1324 Capsule Endoscopy for Obscure GI Bleeding Yields a High Incidence of Significant Treatable Lesions Within Reach of Standard Upper Endoscopy David Elijah, Adel Daas, Patrick Brady Background and Aims: Capsule endoscopy (CE) has been shown to be an effective diagnostic method in patients with obscure gastrointestinal bleeding. Although, designed primarily to evaluate the small intestine, significant lesions are found during CE which are within reach of conventional upper endoscopy. This mirrors the events of ‘‘missed’’ lesions noted during the introduction of push endoscopy. The aim of this study was to quantify and characterize lesions found on CE within the reach of a standard upper endoscopy. Methods: A retrospective review was conducted of all CE performed for evaluation of obscure GI bleeding from March 2003 to November 2004. All patients had previously undergone at least one negative esophagogastroduodenoscopy and colonoscopy. Patients were excluded if CE was done for any indication other than gastrointestinal bleeding or iron deficiency anemia. CE was done using the Given M2A capsule on all patients. Results: CE was performed in 203 patients (128 women, 75 men, mean age 66.5 G 14.1 years). Significant lesions that could account for the patient’s anemia were found in the esophagus, stomach and duodenum in 86 patients (42.4%). Significant lesions noted were 7 gastric ulcers (8.1%), 5 duodenal ulcers (5.8%), 15 angioectasias (17.4%), 7 GAVE (8.1%), 1 gastric varix (1.2%), 1 Cameron lesion, 31 gastritis (36.0%), 7 duodenitis (8.1%), and 1 esophagitis. Patients with esophagitis, gastritis, and/or duodenitis without erosions, or those with erosion, but clear evidence of distal bleeding were not included. The majority of these lesions were amenable to medical or endoscopic therapy. In these 86 patients, recommended medical therapy in 57, endoscopic intervention in 28, and surgical intervention in 1. Conclusion: This study demonstrates that CE finds significant lesions that can be responsible for gastrointestinal blood loss in the esophagus, stomach and duodenum well within reach of a standard endoscope. Careful attention must be paid during CE to the esophagus, stomach and duodenum to avoid missing significant findings. Repeat upper gastrointestinal endoscopy should be considered on an individual basis before performing a CE.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB163
M1321 The World Around the Gastric Polyp Riaz Dor, Patrick DuBois, Kalpesh Besherdas, Steven Mann, Niall van Someren Background: Gastric epithelial polyps are an infrequent endoscopic finding with a prevalence of about 2%. These can be divided into largely 3 histological types; hyperplastic (60%), fundic gland polyps (25%), and adenomas (10%). Hyperplastic and, to a lesser degree, adenomatous polyps have been associated with chronic gastritis, gastric atrophy and intestinal metaplasia in the surrounding gastric mucosa. Whereas this association does not exist with gastric fundal polyps. Often the focus at endoscopy is on the polyp and not the surrounding tissues. The aim of this study was to investigate this relationship further. Aims & Methods: Prospective analysis of 1097 patients referred to the endoscopy unit for a variety of indications revealed a total 32 polyps. At endoscopy the polyp was snared and sent for histological analysis along with 6 biopsies from the mucosa surrounding the polyp. Results: 32 patients (20 male, 12 female) with polyps were found. Age range 38-94 years. Polyp size 3-50 mm. Frequency of polyps: 24 (75%) hyperplastic, 6 (22%) fundal gland, 1 (3%) adenomatous, 1 (3%) inflammatory. Polyps were more commonly seen in those over 50 years of age. Males were more likely to have hyperplastic polyps. The mucosa surrounding hyperplastic polyp was associated with chronic active gastritis in 92% of cases (p ! 0.05) ,with gastric atrophy in 15% (p ! 0.05) and intestinal metaplasia in 6%. No association was found between the size or site of polyp. However, as expected, the presence of Helicobacter pylori was a risk factor for gastric atrophy and intestinal metaplasia. Conclusion: The presence of apparent gastric polyps is an important finding and, as this study shows, may herald potential mucosal abnormalities in the surrounding areas, thus making biopsies of such polyps as well as the surrounding mucosa an important management policy.
M1322 Capsule Endoscopy (CE) in Evaluation of Patients with Celiac Disease (CD) Elena Dubcenco, Khursheed N. Jeejeebhoy, Rima Petroniene, Ralph C. Warren, Clifford A. Ottaway, Geoffrey W. Gardiner, Cathy J. Streutker, Jeffrey P. Baker Aim: To establish the accuracy of CE in diagnosing villous atrophy (VA) using small bowel (SB) histology as a ‘‘gold standard’’. To evaluate the ability of CE to correctly interpret mucosal changes in CD patients after introduction of a gluten free diet (GFD). Methods: Participants (CD and control group) had serology, upper endoscopy, SB biopsy and CE. Standard endoscopic criteria in identifying VA were applied to CE. An investigator blinded to other tests’ findings randomly reviewed CE images. Patients’ identification details were coded. Histological confirmation of CD (Marsh’s III-IV type) was considered diagnostic of CD. All tests were repeated in CD group to assess patients’ response after 6 months of the GFD. A dedicated dietitian assessed patients’ baseline gluten intake followed by compliance to the GFD. The investigator blinded to other tests’ findings reviewed and compared CE images taken before with the images taken after introduction of the GFD. Results: Evaluated 41 (29 CD, 12 healthy controls). Mean age-45.3 yr, SDZ15.94 (range 17-77). 1 patient’s data (CD group) was excluded from the analysis (Marsh’s I-II type). In the diagnosis of VA, CE yielded a sensitivity/a specificity of 89.3%/91.7%, positive/negative predictive values of 96.2%/78.6%. Importantly, CE revealed 3 CD patients with ulcerative jejunitis. 15 CD patients were re-evaluated after 6 months of the GFD. 12/15 improved histologically and clinically. 3/15 did not experience any changes in their condition. 1 of the 3 was found completely and 1 partially non-complaint to the GFD. When compared to histology CE correctly interpreted positive/negative mucosal changes after introduction of the GFD in 12/15 patients (80%). Conclusions: CE may be suggested for further work up of histologically confirmed CD patients. With its ability to visualize the entire SB and high accuracy in identifying VA, CE could provide a non-invasive way of evaluating CD patients, monitoring the response to the GFD as well as lifelong screening for CD related complications such as ulcerative jejunitis or malignancy.
www.mosby.com/gie
M1323 Double-Balloon Endoscopy for Diagnoses of Small Bowel Tumors Akihito Ehara, Shu Tanaka, Atsushi Tatsuguchi, Katya Gudis, Keigo Mitsui, Tsuyoshi Kobayashi, Yoshihisa Sekita, Tsuguhiko Seo, Masaoki Yonezawa, Yoshiaki Shibata, Kazuhiro Nagata, Shunji Fujimori, Teruyuki Kishida, Choitsu Sakamoto Backgrounds and Aims: Small bowel tumors accounts for only 1-2% of all gastrointestinal tumors. In addition, small bowel tumors often go undiagnosed, given the limitations of traditional endoscopy, and radiological procedures such as enteroclysis and CT scan, in visualizing the small intestine. Furthermore, the relative inaccessibility of the small intestine precludes easy retrieval of samples for histopathological analysis without resorting to surgery. Yamamoto et al. have developed a new endoscopy system, called double-balloon endoscopy (DBES), which enables endoscopic scrutiny and treatment of the entire small bowel. The aim of this study was to evaluate the value and potential of this endoscopic system in the diagnosis of small bowel tumors. Patients and Methods: The DBES (EN-450P5/20, EN-450T5/20, Fujinon, Fuji Photo Optical Co., Ltd., Saitama, Japan) was used to perform 90 enteroscopies in 65 patients between June 2003 and November 2004 at Nippon Medical School Hospital. The system was assessed on the basis of diagnostic yields and complications. Results: Small bowel tumors were detected in 8 (12%) of 65 patients. Forceps biopsy specimens were obtained through DBES and histopathological examination was possible in all 8 patients. Of the 8 patients, 5 were males and 3 females, with ages ranging from 42 to 82 years (average, 65 years). Chief complaints were gastrointestinal bleeding in 5 patients, anemia in 2 patients and diarrhea in 1 patient. The tumors were located in the jejunum in 3 patients, and in the ileum in 5 patients. Tumors were diagnosed histopathologically as: gastrointestinal tumor (GIST) in 5 (67%) patients, malignant lymphoma in 2 (25%) patients and adenocarcinoma in 1 (12%) patient. Of the 5 patients with GIST, 4 had celiotomy and 1 had celiotomy, with subsequent adjuvant chemotherapy. Of the 2 patients with malignant lymphoma, one patient had chemotherapy; the other, celiotomy, with subsequent adjuvant chemotherapy. One patient with adenocarcinoma had laparoscopic enterectomy. We encountered no complications during DBES procedures. Conclusions: DBES allows through examination of the entire small bowel, with a 100% success rate of histopathlogical assessment endoscopically. The procedure is safe and of great diagnostic value and aids in the appropriate selection of therapeutic modalities.
M1324 Capsule Endoscopy for Obscure GI Bleeding Yields a High Incidence of Significant Treatable Lesions Within Reach of Standard Upper Endoscopy David Elijah, Adel Daas, Patrick Brady Background and Aims: Capsule endoscopy (CE) has been shown to be an effective diagnostic method in patients with obscure gastrointestinal bleeding. Although, designed primarily to evaluate the small intestine, significant lesions are found during CE which are within reach of conventional upper endoscopy. This mirrors the events of ‘‘missed’’ lesions noted during the introduction of push endoscopy. The aim of this study was to quantify and characterize lesions found on CE within the reach of a standard upper endoscopy. Methods: A retrospective review was conducted of all CE performed for evaluation of obscure GI bleeding from March 2003 to November 2004. All patients had previously undergone at least one negative esophagogastroduodenoscopy and colonoscopy. Patients were excluded if CE was done for any indication other than gastrointestinal bleeding or iron deficiency anemia. CE was done using the Given M2A capsule on all patients. Results: CE was performed in 203 patients (128 women, 75 men, mean age 66.5 G 14.1 years). Significant lesions that could account for the patient’s anemia were found in the esophagus, stomach and duodenum in 86 patients (42.4%). Significant lesions noted were 7 gastric ulcers (8.1%), 5 duodenal ulcers (5.8%), 15 angioectasias (17.4%), 7 GAVE (8.1%), 1 gastric varix (1.2%), 1 Cameron lesion, 31 gastritis (36.0%), 7 duodenitis (8.1%), and 1 esophagitis. Patients with esophagitis, gastritis, and/or duodenitis without erosions, or those with erosion, but clear evidence of distal bleeding were not included. The majority of these lesions were amenable to medical or endoscopic therapy. In these 86 patients, recommended medical therapy in 57, endoscopic intervention in 28, and surgical intervention in 1. Conclusion: This study demonstrates that CE finds significant lesions that can be responsible for gastrointestinal blood loss in the esophagus, stomach and duodenum well within reach of a standard endoscope. Careful attention must be paid during CE to the esophagus, stomach and duodenum to avoid missing significant findings. Repeat upper gastrointestinal endoscopy should be considered on an individual basis before performing a CE.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB163