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Polyps At Double-Balloon Enteroscopy (DBE) and Capsule Endoscopy (CE)
Abstracts
M1304 Diagnostic Yield of Double-Balloon Enteroscopy in Patients with Various Ulcerative Diseases of the Small Intestine: Present Status and Problems Concerning Endoscopic Diagnosis Noriaki Manabe, Shinji Tanaka, Akira Fukumoto, Yoshiaki Matsumoto, Toshiki Yamaguchi, Madoka Nakao, Yutaka Mitsuoka, Jiro Hata, Ken Haruma, Kazuaki Chayama
M1306 Accuracy of Localization of Small Bowel Disorder Detected By Capsule Endoscopy Masanao Nakamura, Yasumasa Niwa, Naoki Ohmiya, Ryouji Miyahara, Akira Ohashi, Tetsuo Matsuura, Shusuke Kitabatake, Daigo Arakawa, Yoichi Iguchi, Wataru Honda, Osamu Maeda, Takafumi Ando, Akihiro Itoh, Yoshiki Hirooka, Hidemi Goto
Background and Aims: Various diseases of the small intestine are now detected by double-balloon enteroscopy (DBE), which has revolutionized endoscopy of the small intestine. One of the most common DBE findings is ulcerative lesion. The etiology of ulcerative lesions varies. It is a matter of great importance to diagnose these lesions, including etiology, accurately. The aim of this investigation was to evaluate the diagnostic yield of DBE in patients with ulcerative lesions of the small intestine. Subjects and Methods: Between August 1, 2003, and October 31, 2005, 118 patients underwent DBE, and 52 patients (30 men, 22 women; mean age, 52.8 years) in whom a total of 159 ulcerative lesions in the small intestine were detected were enrolled in this study. After detailed endoscopic observation, biopsy specimens were obtained, and double-contrast barium examination was performed as deemed necessary. Final diagnosis was made comprehensively on the basis of endoscopic findings, pathologic findings and clinical course. Results: The most common indication for DBE in these patients was gastrointestinal bleeding (n Z 31, 59.6%). There were 12 patients (23.1%) with ulcerative lesions related to tumor (Ul-tm) and 40 patients (76.9%) with ulcerative lesions related to chronic inflammation (Ul-inf). Ten patients (83.3%) with Ul-tm had lesions located in the upper small intestine; 29 patients (72.5%) with Ul-inf had lesions located in the lower small intestine. Small (3-4 mm), circular, scattered ulcerations were commonly detected endoscopically. Twelve patients showed stenotic lesions caused by Crohn’s disease (n Z 5), tuberculosis (n Z 4) and other causes (n Z 3). A definitive diagnosis was obtained by DBE in 17 patients (42.5%). A definitive diagnosis was obtained by double-contrast barium examination after DBE in 4 patients (10%) and by consideration of DBE findings and the clinical course in 8 patients (20%). Seven cases (17.5%) remained undiagnosed. Thus, most lesions of the small intestine could be diagnosed definitively from characteristic endoscopic findings. However, some ulcerative lesions, especially those related to chronic inflammation, could not be diagnosed on the basis of a single DBE examination because configurations of the lesions varied easily according to disease stage or treatment. Conclusions: Our results suggest that about half ulcerative lesions in about 50% of patients cannot be diagnosed definitively on the basis of a single endoscopic observation.
Background and Study Aims: Capsule endoscopy (CE) is a promising examination for the entire small bowel. However, accuracy of localization of small bowel disorder detected by CE has not been fully elucidated. The aim of this study is to assess the accuracy of CE localization by comparison with another precise localization modality’s findings on the same small bowel lesion. Patients and Methods: Between June 2004 and October 2005, among 76 patients who underwent CE for small bowel disorders, 16 patients whose CE reached the cecum within the examination time and who had a positive finding that was consistent with another examination’s finding were enrolled in this study. For localization, the whole small bowel was divided into six equal parts (upper-, middle-, lower-jejunum and upper-, middle-, lower-ileum) and a positive finding was decided on by which of the six parts the lesion was located in by each device. The decided parts were compared between examinations. Results: The localizations by other modalities were completed using double-balloon enteroscopy (DBE) in 11 patients, surgery in 3, intra-operative endoscopy in 1, and small bowel follow-through in 1. We chose the appropriate one of the six parts of the small bowel for localization for every positive finding. Fourteen findings (87.5%) were in exact agreement on the localization part. In the two cases wherein lesion localizations were inconsistent between examinations, these differences were within one part of the six parts into which the small bowel was divided. In one patient with different results, the localization of the bleeding tumor detected by CE was the lower jejunum, thus we carried out DBE via the antegrade method, but could not reach the tumor. Subsequently, we were able to discover the tumor via the retrograde method. The position of the tumor in surgery was 260 cm from Treitz’s ligament and 160 cm from the ileocecal valve. In the other patient with inconsistent results, the familial polyp was located in the middle jejunum on the CE localization system, but the polyp was identified in the upper jejunum near Treitz’s ligament by DBE. We consider the localization by CE to be reliable in the great majority of patients, thus allowing CE’s localization to be accepted as an index for the determination of management. Conclusions: In many patients in whom CE reached the cecum within the examination time, it was proved that the localization by CE was accurate. However, the CE localization in patients with bleeding lesions or polyps needs to be carefully scrutinized.
M1305 Wireless Capsule Endoscopy in Suspected Crohn’s Disease: Correlation of Findings with IBD Serology Jonathan a. Erber, William F. Erber, Sharon K. Sagiv, Susan Sagiv Introduction: Wireless Capsule Endoscopy (WCE) provides direct visualization of mucosal abnormalities throughout the entire small intestine. IBD serologies have been shown to be a useful marker in IBD. The combination of WCE with IBD serologies may be the most sensitive means of diagnosing and identifying the extent and degree of small intestinal Crohn’s disease (CD). Methods: A retrospective analysis of 86 patients who underwent WCE with the PillCam Sb (Given Imaging, Yoqneam, Israel) for suspected CD between January 2003 and November 2005. 4 groups of patients were identified: 28 with abdominal pain, diarrhea, guaiac C stools, and iron deficiency anemia; 24 with abdominal pain and diarrhea; 11 with abdominal pain; 23 with indeterminate colitis. All patients underwent pan-endoscopy, most ileoscopy, and small bowel series. WCE studies were reviewed by 2 independent readers. Findings were classified as definite or possible for CD, non-specific, or normal. Definite findings included the presence of greater than 3 ulcers, numerous aphthous ulcers, edema, nodularity, and stricture. Findings considered as possible included the presence of a single aphthous ulcer with edema and nodularity. Non-specific inflammatory changes consisted of erythema, edema, nodularity, and mucosal breaks. IBD serologies (ASCA IgA, IgG, p-ANCA) were obtained from 52 patients. Patients on aspirin, clopidogrel, NSAIDs, or with known CD, were excluded. Results: There were 53 females, 33 males; average age 47.4 (range 11-82). 9/28 patients with abdominal pain, diarrhea, guaiac C stools, and iron deficiency anemia had definite Capsule Endoscopy findings (4 with diffuse small intestinal involvement), 5 possible, 11 non-specific, 3 normal. 3/24 patients with abdominal pain and diarrhea had definite findings, 6 possible, 13 non-specific, 2 normal. 1/11 patients with abdominal pain alone had definite findings (diffuse small intestinal involvement), 2 possible, 8 non-specific. 4/23 patients with indeterminate colitis had definite findings, 6 possible, 7 non-specific, 6 normal. 84% (16/19) of patients with C IBD serologies had definite or possible capsule findings; 10/12 patients with definite findings had C markers; 6/15 with possible findings had C markers; 2/21 with non-specific findings had C markers; 1 with normal findings had C markers. Conclusion: C WCE findings for CD strongly correlated with C IBD serologies. C WCE findings for CD were highest for patients with abdominal pain, diarrhea, guaiac C stools, and iron deficiency anemia. Combining WCE with IBD serologies improves the diagnostic staging of patients with CD. This may ultimately impact on therapy.
www.giejournal.org
M1307 Diagnosis and Treatment of Small Intestinal Tumors/Polyps At Double-Balloon Enteroscopy (DBE) and Capsule Endoscopy (CE) Wataru Honda, Naoki Ohmiya, Daigo Arakawa, Masanao Nakamura, Hironobu Kanazawa, Ayumu Taguchi, Taisaku Hasegawa, Yasushi Matsuyama, Akihiro Itoh, Yoshiki Hirooka, Osamu Maeda, Takafumi Ando, Yasumasa Niwa, Hidemi Goto Background and Aims: CE has allowed noninvasive imaging of the majority of the small intestine in physiological condition. DBE has enabled endoscopic scrutiny and interventional therapies of the small intestine. We evaluated the usefulness of DBE and CE to diagnose and treat small intestinal tumors/polyps. Patients and Methods: Of 187 patients (pts) who had undergone DBE, small intestinal tumors/polyps were diagnosed in 32 pts (20 male, 12 female) between June 2003 and October 2005. Seven of 32 patients underwent CE within one week prior to DBE. Results: All tumors/polyps in 32 pts were histologically diagnosed by biopsy or endoscopic mucosal resection (EMR) at DBE. Diagnosis of tumors/polyps was as follows; Peutz-Jeghers polyps (PJP, n Z 9), adenomatous polyps with familial adenomatous polyposis (n Z 5), malignant lymphoma (ML, n Z 5), gastrointestinal stromal tumor (n Z 2), increasing folliculus lymphaticus (n Z 2), lymphangioma (n Z 2), submucosal adenocarcinoma (n Z 1), metastatic small intestinal cancer (n Z 1), tubular adenoma (n Z 1), carcinoid (n Z 1), aberrant pancreas (n Z 1), leiomyoma (n Z 1), and Inflammatory polyp (n Z 1). Tumors/polyps were successfully treated by EMR in 9 patients with PJP, one pt with aberrant pancreas, one pt with leiomyoma, one pt with lymphangioma, and one pt with tubular adenoma Two GIST, five ML, one submucosal adonocarcionma, and one metastasis were treated by surgical resection. Complications were acute pancreatitis at DBE from the oral approach in one pt with PJ syndrome possibly due to insertional difficulty from polysurgery, and hemorrhage at DBE from the anal approach in one pt with aberrant pancreas. One to thirty PJPs were successfully resected at one to three DBE in one pt. All lesions were detected at CE for screening purose in five pts (one PJS, one submucosal adenocarcinoma, one malignant lymphoma, one GIST, one carcinoid). Two pts underwent CE for follow-up after EMR. In one pt with PJS, CE revealed several polyps less than 10 mm were detected two years after EMR. In one pt with aberrant pancreas, CE revealed hemorrhage from post-EMR ulcer two days after EMR and hemostasis was performed by clipping. Conclusions: DBE was useful for diagnosis and treatment of small intestinal tumors/polyps. CE was effective for screening and follow-up after enteroscopic treatment.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB167
M1304 Diagnostic Yield of Double-Balloon Enteroscopy in Patients with Various Ulcerative Diseases of the Small Intestine: Present Status and Problems Concerning Endoscopic Diagnosis Noriaki Manabe, Shinji Tanaka, Akira Fukumoto, Yoshiaki Matsumoto, Toshiki Yamaguchi, Madoka Nakao, Yutaka Mitsuoka, Jiro Hata, Ken Haruma, Kazuaki Chayama
M1306 Accuracy of Localization of Small Bowel Disorder Detected By Capsule Endoscopy Masanao Nakamura, Yasumasa Niwa, Naoki Ohmiya, Ryouji Miyahara, Akira Ohashi, Tetsuo Matsuura, Shusuke Kitabatake, Daigo Arakawa, Yoichi Iguchi, Wataru Honda, Osamu Maeda, Takafumi Ando, Akihiro Itoh, Yoshiki Hirooka, Hidemi Goto
Background and Aims: Various diseases of the small intestine are now detected by double-balloon enteroscopy (DBE), which has revolutionized endoscopy of the small intestine. One of the most common DBE findings is ulcerative lesion. The etiology of ulcerative lesions varies. It is a matter of great importance to diagnose these lesions, including etiology, accurately. The aim of this investigation was to evaluate the diagnostic yield of DBE in patients with ulcerative lesions of the small intestine. Subjects and Methods: Between August 1, 2003, and October 31, 2005, 118 patients underwent DBE, and 52 patients (30 men, 22 women; mean age, 52.8 years) in whom a total of 159 ulcerative lesions in the small intestine were detected were enrolled in this study. After detailed endoscopic observation, biopsy specimens were obtained, and double-contrast barium examination was performed as deemed necessary. Final diagnosis was made comprehensively on the basis of endoscopic findings, pathologic findings and clinical course. Results: The most common indication for DBE in these patients was gastrointestinal bleeding (n Z 31, 59.6%). There were 12 patients (23.1%) with ulcerative lesions related to tumor (Ul-tm) and 40 patients (76.9%) with ulcerative lesions related to chronic inflammation (Ul-inf). Ten patients (83.3%) with Ul-tm had lesions located in the upper small intestine; 29 patients (72.5%) with Ul-inf had lesions located in the lower small intestine. Small (3-4 mm), circular, scattered ulcerations were commonly detected endoscopically. Twelve patients showed stenotic lesions caused by Crohn’s disease (n Z 5), tuberculosis (n Z 4) and other causes (n Z 3). A definitive diagnosis was obtained by DBE in 17 patients (42.5%). A definitive diagnosis was obtained by double-contrast barium examination after DBE in 4 patients (10%) and by consideration of DBE findings and the clinical course in 8 patients (20%). Seven cases (17.5%) remained undiagnosed. Thus, most lesions of the small intestine could be diagnosed definitively from characteristic endoscopic findings. However, some ulcerative lesions, especially those related to chronic inflammation, could not be diagnosed on the basis of a single DBE examination because configurations of the lesions varied easily according to disease stage or treatment. Conclusions: Our results suggest that about half ulcerative lesions in about 50% of patients cannot be diagnosed definitively on the basis of a single endoscopic observation.
Background and Study Aims: Capsule endoscopy (CE) is a promising examination for the entire small bowel. However, accuracy of localization of small bowel disorder detected by CE has not been fully elucidated. The aim of this study is to assess the accuracy of CE localization by comparison with another precise localization modality’s findings on the same small bowel lesion. Patients and Methods: Between June 2004 and October 2005, among 76 patients who underwent CE for small bowel disorders, 16 patients whose CE reached the cecum within the examination time and who had a positive finding that was consistent with another examination’s finding were enrolled in this study. For localization, the whole small bowel was divided into six equal parts (upper-, middle-, lower-jejunum and upper-, middle-, lower-ileum) and a positive finding was decided on by which of the six parts the lesion was located in by each device. The decided parts were compared between examinations. Results: The localizations by other modalities were completed using double-balloon enteroscopy (DBE) in 11 patients, surgery in 3, intra-operative endoscopy in 1, and small bowel follow-through in 1. We chose the appropriate one of the six parts of the small bowel for localization for every positive finding. Fourteen findings (87.5%) were in exact agreement on the localization part. In the two cases wherein lesion localizations were inconsistent between examinations, these differences were within one part of the six parts into which the small bowel was divided. In one patient with different results, the localization of the bleeding tumor detected by CE was the lower jejunum, thus we carried out DBE via the antegrade method, but could not reach the tumor. Subsequently, we were able to discover the tumor via the retrograde method. The position of the tumor in surgery was 260 cm from Treitz’s ligament and 160 cm from the ileocecal valve. In the other patient with inconsistent results, the familial polyp was located in the middle jejunum on the CE localization system, but the polyp was identified in the upper jejunum near Treitz’s ligament by DBE. We consider the localization by CE to be reliable in the great majority of patients, thus allowing CE’s localization to be accepted as an index for the determination of management. Conclusions: In many patients in whom CE reached the cecum within the examination time, it was proved that the localization by CE was accurate. However, the CE localization in patients with bleeding lesions or polyps needs to be carefully scrutinized.
M1305 Wireless Capsule Endoscopy in Suspected Crohn’s Disease: Correlation of Findings with IBD Serology Jonathan a. Erber, William F. Erber, Sharon K. Sagiv, Susan Sagiv Introduction: Wireless Capsule Endoscopy (WCE) provides direct visualization of mucosal abnormalities throughout the entire small intestine. IBD serologies have been shown to be a useful marker in IBD. The combination of WCE with IBD serologies may be the most sensitive means of diagnosing and identifying the extent and degree of small intestinal Crohn’s disease (CD). Methods: A retrospective analysis of 86 patients who underwent WCE with the PillCam Sb (Given Imaging, Yoqneam, Israel) for suspected CD between January 2003 and November 2005. 4 groups of patients were identified: 28 with abdominal pain, diarrhea, guaiac C stools, and iron deficiency anemia; 24 with abdominal pain and diarrhea; 11 with abdominal pain; 23 with indeterminate colitis. All patients underwent pan-endoscopy, most ileoscopy, and small bowel series. WCE studies were reviewed by 2 independent readers. Findings were classified as definite or possible for CD, non-specific, or normal. Definite findings included the presence of greater than 3 ulcers, numerous aphthous ulcers, edema, nodularity, and stricture. Findings considered as possible included the presence of a single aphthous ulcer with edema and nodularity. Non-specific inflammatory changes consisted of erythema, edema, nodularity, and mucosal breaks. IBD serologies (ASCA IgA, IgG, p-ANCA) were obtained from 52 patients. Patients on aspirin, clopidogrel, NSAIDs, or with known CD, were excluded. Results: There were 53 females, 33 males; average age 47.4 (range 11-82). 9/28 patients with abdominal pain, diarrhea, guaiac C stools, and iron deficiency anemia had definite Capsule Endoscopy findings (4 with diffuse small intestinal involvement), 5 possible, 11 non-specific, 3 normal. 3/24 patients with abdominal pain and diarrhea had definite findings, 6 possible, 13 non-specific, 2 normal. 1/11 patients with abdominal pain alone had definite findings (diffuse small intestinal involvement), 2 possible, 8 non-specific. 4/23 patients with indeterminate colitis had definite findings, 6 possible, 7 non-specific, 6 normal. 84% (16/19) of patients with C IBD serologies had definite or possible capsule findings; 10/12 patients with definite findings had C markers; 6/15 with possible findings had C markers; 2/21 with non-specific findings had C markers; 1 with normal findings had C markers. Conclusion: C WCE findings for CD strongly correlated with C IBD serologies. C WCE findings for CD were highest for patients with abdominal pain, diarrhea, guaiac C stools, and iron deficiency anemia. Combining WCE with IBD serologies improves the diagnostic staging of patients with CD. This may ultimately impact on therapy.
www.giejournal.org
M1307 Diagnosis and Treatment of Small Intestinal Tumors/Polyps At Double-Balloon Enteroscopy (DBE) and Capsule Endoscopy (CE) Wataru Honda, Naoki Ohmiya, Daigo Arakawa, Masanao Nakamura, Hironobu Kanazawa, Ayumu Taguchi, Taisaku Hasegawa, Yasushi Matsuyama, Akihiro Itoh, Yoshiki Hirooka, Osamu Maeda, Takafumi Ando, Yasumasa Niwa, Hidemi Goto Background and Aims: CE has allowed noninvasive imaging of the majority of the small intestine in physiological condition. DBE has enabled endoscopic scrutiny and interventional therapies of the small intestine. We evaluated the usefulness of DBE and CE to diagnose and treat small intestinal tumors/polyps. Patients and Methods: Of 187 patients (pts) who had undergone DBE, small intestinal tumors/polyps were diagnosed in 32 pts (20 male, 12 female) between June 2003 and October 2005. Seven of 32 patients underwent CE within one week prior to DBE. Results: All tumors/polyps in 32 pts were histologically diagnosed by biopsy or endoscopic mucosal resection (EMR) at DBE. Diagnosis of tumors/polyps was as follows; Peutz-Jeghers polyps (PJP, n Z 9), adenomatous polyps with familial adenomatous polyposis (n Z 5), malignant lymphoma (ML, n Z 5), gastrointestinal stromal tumor (n Z 2), increasing folliculus lymphaticus (n Z 2), lymphangioma (n Z 2), submucosal adenocarcinoma (n Z 1), metastatic small intestinal cancer (n Z 1), tubular adenoma (n Z 1), carcinoid (n Z 1), aberrant pancreas (n Z 1), leiomyoma (n Z 1), and Inflammatory polyp (n Z 1). Tumors/polyps were successfully treated by EMR in 9 patients with PJP, one pt with aberrant pancreas, one pt with leiomyoma, one pt with lymphangioma, and one pt with tubular adenoma Two GIST, five ML, one submucosal adonocarcionma, and one metastasis were treated by surgical resection. Complications were acute pancreatitis at DBE from the oral approach in one pt with PJ syndrome possibly due to insertional difficulty from polysurgery, and hemorrhage at DBE from the anal approach in one pt with aberrant pancreas. One to thirty PJPs were successfully resected at one to three DBE in one pt. All lesions were detected at CE for screening purose in five pts (one PJS, one submucosal adenocarcinoma, one malignant lymphoma, one GIST, one carcinoid). Two pts underwent CE for follow-up after EMR. In one pt with PJS, CE revealed several polyps less than 10 mm were detected two years after EMR. In one pt with aberrant pancreas, CE revealed hemorrhage from post-EMR ulcer two days after EMR and hemostasis was performed by clipping. Conclusions: DBE was useful for diagnosis and treatment of small intestinal tumors/polyps. CE was effective for screening and follow-up after enteroscopic treatment.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB167