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Observation and Treatment of Small Bowel Diseases Using Single Balloon Endoscope
Abstracts
bleeding was divided into obscure overt (n Z 66) and obscure occult (n Z 18). Pts without pathological findings in DBE underwent a repeated EGD and colonoscopy. Results: 114 DBE procedures (per-oral route n Z 82, per-anal route n Z 34) were performed in 84 pts. A SB etiology of GI-bleeding was found in 45 pts (53.6%). SB bleeding was classified into obscure overt in 36 pts and obscure occult in 9 pts. Findings included angioectasias/angiodysplasias (n Z 24), portal-hypertensive jejunopathy (n Z 6), erosive and ulcerative jejunitis (n Z 11), SB tumors (n Z 3) and one SB diverticulum. Lesions outside the small bowel as possible source of GI bleeding were found in 25 pts (29.8%). Of these 25 pts 22 were symptomatic with obscure overt and 3 with obscure occult GI bleeding. Findings outside the SB included colonic diverticulosis (n Z 8), gastric or duodenal ulcers (n Z 7), colonic angioectasias/angiodysplasias (n Z 5), terminal ileitis (n Z 4) and erosive gastritis (n Z 1). In 14 pts (16.6%) a bleeding source could be identified neither by DBE nor by EGD and colonoscopy despite 8 being symptomatic with obscure overt GI bleeding. Conclusions: Mid-gut bleeding was detected by DBE in more than 50% of pts. The frequency of non-small bowel lesions potentially explaining the source of GI bleeding in pts referred for DBE was 29.8%. Therefore, repeat EGD and ileocolonoscopy should be taken into consideration before DBE, as it can significantly reduce the DBE workload and is likely to impact on costs.
T1653 Wireless Capsule Endoscopy Gastric and Small Bowel Transit Time and Completeness of the Examination in Patients with Glucose Tolerance Abnormalities Or Renal Dysfunction in Japan Mitsunori Maeda, Kazunari Kanke, Michiko Nakano, Mina Hoshino, Michiko Yamagata, Akira Terano, Hideyuki Hiraishi Purpose: Wireless capsule endoscopy (WCE) is one of the most important investigations for small bowel examination. The aim of the study was to measure WCE gastric transit time (GTT) and small bowel transit time (SBTT) and the rate of caecal visualization in patients with glucose tolerance abnormalities or renal dysfunction. Patients and Methods: We retrospectively examined 135 patients (92 female; mean aged, 51.7 yr; 15-94 yr) who underwent WCE at Dokkyo Medical University hospital from February 2003 to November 2007. We divided them into Group DM (glucose tolerance abnormalities groups, fasting blood sugar O110 mg/dl or Hemoglobin A1c O5.8 %, n Z 16), Group RF (renal dysfunction groups, serum creatinine O1.1 mg/dl, n Z 22), Group CO (control groups except for Group DM and RF, n Z 98). Two independent experienced investigators measured transit times and the rate of caecal visualization. Results: GTTwas significantly longer in Group DM (59.3 min, 2.3-358.8 min) compared to Group CO (54.6, 2.4-410 min, p ! 0.01), but GTTwas significantly shorter in Group RF (43.7, 4.8-115.2 min, p ! 0.01) compared to Group CO. SBTTwas significantly longer in Group DM (330.0, 243.4-462.4 min) and Group RF (306.5, 211.6408.1 min) compared to Group CO (284.6, 108.5-462.0 min, p ! 0.01). The caecum was visualized in 12/22 (54.5%) Group DM, 7/16 (43.8%) Group RF and 61/98 (62.2%) Group CO (p ! 0.01). Conclusions: This study suggests that patients with glucose tolerance abnormalities or renal dysfunction have significantly prolonged wireless capsule endoscopy small bowl transit time and reduced the rate of caecal visualization compared to control groups.
T1654 Diagnostic and Therapeutic Impact of Double Balloon Enteroscopy in Patients with Crohn‘s Disease Michael Bellutti, Lucia C. Fry, Klaus Mo ¨Nkemu ¨ Ller, Helmut Neumann, Ulrike Von Arnim, Peter Malfertheiner Background: Most patients (pts) with small bowel (SB) Crohn‘s disease (CD) have either colonic or terminal ileal involvement. However, isolated SB involvement occurs in a third of pts with CD. Frequently pts present with perianal fistulas, abdominal pain and diarrhea, but without upper or lower endoscopic evidence of CD. Establishing the diagnosis or evaluating the disease activity in these pts can prove very difficult. Aim: Single-center study to assess the diagnostic and therapeutic value of DBE in pts with suspected or established CD. Methods: Definition of suspected CD: one or more of the following features: perianal fistula, fever, abdominal pain and chronic diarrhea. DBE was performed using a diagnostic or therapeutic enteroscope (Fujinon Corp., Japan). Results: 43 DBE were performed in 35 pts (16 male, 19 female; mean age 42.5 years, range 17-78 years); oral route (n Z 30), anal route (n Z 13), both (n Z 6). 17 pts had known CD and 18 had suspected CD. Indications for DBE: 1) pts with known CD: persistency of symptoms despite appropriate treatment and suspicion of SB involvement, radiological signs of SB stenosis or enterocutaneous fistulas; 2) pts with suspicion of CD: recurrent diarrhea, abdominal pain or perianal fistulas with unremarkable colonoscopic, EGD and radiological findings. Of the 18 pts with suspected CD, 9 (50%) had typical endoscopic signs of active inflammation (aphthous lesions, erosions, ulcers) of either the ileum or the jejunum consistent with CD; seven pts (38%) had normal SB mucosa; DBE in 2 pts failed because of a stenosis of the ileocecal valve or of the jejunum. Of the 17 pts with known CD, 12 (71%) showed signs of endoscopic involvement. Five pts (29%) had no evidence of SB involvement. Four pts with known CD additionally had jejunal or ileal stenosis or jejuno-colonic fistulas. In two pts endoscopic treatment of a jejunal and an ileal stenosis by balloon-dilation resulted in a partial remission of symptoms, one pt with an ileal stenosis was referred to surgery. Conclusions: DBE detected active mucosal SB disease in half of the pts with
www.giejournal.org
suspected CD and 70% of pts with clinically confirmed CD and thus represents a valuable diagnostic tool for SB CD. Endoscopic treatment of stricturizing CD by balloon-dilation seems to be useful but needs further investigation.
T1655 Observation and Treatment of Small Bowel Diseases Using Single Balloon Endoscope Kazuo Ohtsuka, Hiroshi Kashida, Kenta Kodama, Jun-Ichi Ukegawa, Hiroshi Kanie, Ken-Ichi Mizuno, Yui Kudo, Orie Takemura, Shin-Ei Kudo Backgrounds and aims: Recent advances in capsule endoscopy (CE) and double balloon endoscopy (DBE) have enabled an endoscopic approach to small bowel diseases. However, CE is simply a diagnostic tool and DBE is fairly complicated to handle. We developed a single balloon endoscopy (SBE) in cooperation with Olympus Medical Systems. The single balloon enteroscope consists of an endoscope and a splinting tube. In this system, a balloon is attached to the splinting tube, but not to the scope itself. We also used DBE. Here we evaluated the usefulness of SBE for the diagnosis and treatment in small intestinal diseases. Patients and methods: Patients were suspected of having small intestinal diseases after upper and lower gastrointestinal endoscopy. They consisted of 65 cases (16 women, 49 men; range 19-78 years old) that received a total of 102 examinations. Thirty-six cases showed symptoms of gastrointestinal tract bleeding, ten had obstruction, five had abdominal pain, five had enteritis, and five cases were for assessment of Crohn’s disease and four had tumors in the small intestine. We used Single Balloon Enteroscope SIF-Q260 (Olympus, Tokyo, Japan), that consists of the endoscope with working length of 2000 mm and an outer diameter of 9.2 mm and splinting tube with a balloon and an outer diameter of 13.2 mm for 79 examinations and DBE (EN-450P5, T5, Fujion, Tokyo, Japan) for 11 examinations. SBE was performed by single-person insertion method in most cases, though DBE needed two persons. Results: In twenty-one cases, the cause of bleeding was diagnosed as either an ulcer, angiodysplasia, Crohn’s disease, inflammatory polyp, or metastatic cancer, but in nine cases the cause was not identified. The ten obstruction cases were comprised of ulcers, adhesion, Crohn’s disease, jejunal volvulus, and malignant lymphoma. For treatment, clippings were performed for bleeding in six patients, polypectomy for two, reversal of volvulus for one, and balloon dilation for ilial stenosis in one. Examination time of anterograde insertion were 65.3 30.5 minutes for SBE and 74.0 26.9 minutes for DBE. That of retrograde insertion were 57.5 24.6 minutes for SBE and 56.3 24.4 minutes for DBE. No complications were encountered. Conclusion: The newly developed SBE has achieved high diagnostic yields with high quality images. It is easy to set up and to insert with single-person method. It is useful for the diagnosis and endoscopic treatment for small bowel diseases.
T1656 Small Intestinal Mucosal Breaks with Short-Term Administration of Non-Steroidal Anti-Inflammatory Drugs Katya Gudis, Shunji Fujimori, Yukie Yamada, Yoko Takahashi, Tsuguhiko Seo, Akihito Ehara, Tsuyoshi Kobayashi, Keigo Mitsui, Masaoki Yonezawa, Shu Tanaka, Atsushi Tatsuguchi, Choitsu Sakamoto Background & Aims: The concentrations of non-steroidal anti-inflammatory drugs (NSAIDs), bile acids, and intestinal flora in regions of the small intestine differ from other areas in the gastrointestinal tract. Thus, one may speculate that the effect of NSAIDs may also differ in the small intestinal mucosa. The aim of this study is to investigate the effect of short-term NSAID medication on the mucosa of the small intestine. Methods: We enrolled 76 healthy male volunteers between 20 to 45 years of age and with no history of surgery. All study subjects were first examined by baseline capsule endoscopy. We then randomly assigned 43 subjects to undertake a 14-day regimen of NSAID (diclofenac sodium, 25 mg; 3 times daily) medication with proton-pump inhibitors as gastroprotection (omeprazole, 20 mg; once daily). The remaining 33 subjects were channeled into a separate study. After 14 days, the 43 subjects all underwent post-treatment capsule endoscopy, and any mucosal breaks of the small intestine assessed and scored as follows: redness with obvious loss of villi, A; small aphtha, B; erosion, C; ulcer-like, D. The regions within which these lesions were located are expressed as the oral-side, mid-section and anal-side; with each division corresponding to 1/3 the transit time of the capsule endoscope in the small intestine. Results: Four subjects were excluded from analysis due to incomplete capsule endoscopy evaluations of the small intestine, two subjects at baseline and two at post-treatment capsule endoscopy. Baseline endoscopy revealed 27 mucosal breaks in 10 out of 74 subjects (14%), consisting of 4 lesions in the oral-side, 7 in the mid-section, and 16 in the anal-side of the small intestine. The proportion of type C and D lesions found in the anal-side (56%) was significantly higher than in the oral-side, where no such lesions were found (0%). Posttreatment endoscopy identified 140 mucosal breaks in 25 out of 41 subjects (61%) on NSAID medication, and consisted of 74 lesions in the oral-side, 34 in the midsection, and 32 in the anal-side. Thus, there was a significant increase in the number of lesions in the NSAID group, with a higher proportion of lesions located in the oral-side than in the anal-side. Type A lesions were more numerous in the oral-side (49 out of 74: 66%) than in the other two regions, with no significant difference between the number of C and D lesions in the oral (13) and anal (11)
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB271
bleeding was divided into obscure overt (n Z 66) and obscure occult (n Z 18). Pts without pathological findings in DBE underwent a repeated EGD and colonoscopy. Results: 114 DBE procedures (per-oral route n Z 82, per-anal route n Z 34) were performed in 84 pts. A SB etiology of GI-bleeding was found in 45 pts (53.6%). SB bleeding was classified into obscure overt in 36 pts and obscure occult in 9 pts. Findings included angioectasias/angiodysplasias (n Z 24), portal-hypertensive jejunopathy (n Z 6), erosive and ulcerative jejunitis (n Z 11), SB tumors (n Z 3) and one SB diverticulum. Lesions outside the small bowel as possible source of GI bleeding were found in 25 pts (29.8%). Of these 25 pts 22 were symptomatic with obscure overt and 3 with obscure occult GI bleeding. Findings outside the SB included colonic diverticulosis (n Z 8), gastric or duodenal ulcers (n Z 7), colonic angioectasias/angiodysplasias (n Z 5), terminal ileitis (n Z 4) and erosive gastritis (n Z 1). In 14 pts (16.6%) a bleeding source could be identified neither by DBE nor by EGD and colonoscopy despite 8 being symptomatic with obscure overt GI bleeding. Conclusions: Mid-gut bleeding was detected by DBE in more than 50% of pts. The frequency of non-small bowel lesions potentially explaining the source of GI bleeding in pts referred for DBE was 29.8%. Therefore, repeat EGD and ileocolonoscopy should be taken into consideration before DBE, as it can significantly reduce the DBE workload and is likely to impact on costs.
T1653 Wireless Capsule Endoscopy Gastric and Small Bowel Transit Time and Completeness of the Examination in Patients with Glucose Tolerance Abnormalities Or Renal Dysfunction in Japan Mitsunori Maeda, Kazunari Kanke, Michiko Nakano, Mina Hoshino, Michiko Yamagata, Akira Terano, Hideyuki Hiraishi Purpose: Wireless capsule endoscopy (WCE) is one of the most important investigations for small bowel examination. The aim of the study was to measure WCE gastric transit time (GTT) and small bowel transit time (SBTT) and the rate of caecal visualization in patients with glucose tolerance abnormalities or renal dysfunction. Patients and Methods: We retrospectively examined 135 patients (92 female; mean aged, 51.7 yr; 15-94 yr) who underwent WCE at Dokkyo Medical University hospital from February 2003 to November 2007. We divided them into Group DM (glucose tolerance abnormalities groups, fasting blood sugar O110 mg/dl or Hemoglobin A1c O5.8 %, n Z 16), Group RF (renal dysfunction groups, serum creatinine O1.1 mg/dl, n Z 22), Group CO (control groups except for Group DM and RF, n Z 98). Two independent experienced investigators measured transit times and the rate of caecal visualization. Results: GTTwas significantly longer in Group DM (59.3 min, 2.3-358.8 min) compared to Group CO (54.6, 2.4-410 min, p ! 0.01), but GTTwas significantly shorter in Group RF (43.7, 4.8-115.2 min, p ! 0.01) compared to Group CO. SBTTwas significantly longer in Group DM (330.0, 243.4-462.4 min) and Group RF (306.5, 211.6408.1 min) compared to Group CO (284.6, 108.5-462.0 min, p ! 0.01). The caecum was visualized in 12/22 (54.5%) Group DM, 7/16 (43.8%) Group RF and 61/98 (62.2%) Group CO (p ! 0.01). Conclusions: This study suggests that patients with glucose tolerance abnormalities or renal dysfunction have significantly prolonged wireless capsule endoscopy small bowl transit time and reduced the rate of caecal visualization compared to control groups.
T1654 Diagnostic and Therapeutic Impact of Double Balloon Enteroscopy in Patients with Crohn‘s Disease Michael Bellutti, Lucia C. Fry, Klaus Mo ¨Nkemu ¨ Ller, Helmut Neumann, Ulrike Von Arnim, Peter Malfertheiner Background: Most patients (pts) with small bowel (SB) Crohn‘s disease (CD) have either colonic or terminal ileal involvement. However, isolated SB involvement occurs in a third of pts with CD. Frequently pts present with perianal fistulas, abdominal pain and diarrhea, but without upper or lower endoscopic evidence of CD. Establishing the diagnosis or evaluating the disease activity in these pts can prove very difficult. Aim: Single-center study to assess the diagnostic and therapeutic value of DBE in pts with suspected or established CD. Methods: Definition of suspected CD: one or more of the following features: perianal fistula, fever, abdominal pain and chronic diarrhea. DBE was performed using a diagnostic or therapeutic enteroscope (Fujinon Corp., Japan). Results: 43 DBE were performed in 35 pts (16 male, 19 female; mean age 42.5 years, range 17-78 years); oral route (n Z 30), anal route (n Z 13), both (n Z 6). 17 pts had known CD and 18 had suspected CD. Indications for DBE: 1) pts with known CD: persistency of symptoms despite appropriate treatment and suspicion of SB involvement, radiological signs of SB stenosis or enterocutaneous fistulas; 2) pts with suspicion of CD: recurrent diarrhea, abdominal pain or perianal fistulas with unremarkable colonoscopic, EGD and radiological findings. Of the 18 pts with suspected CD, 9 (50%) had typical endoscopic signs of active inflammation (aphthous lesions, erosions, ulcers) of either the ileum or the jejunum consistent with CD; seven pts (38%) had normal SB mucosa; DBE in 2 pts failed because of a stenosis of the ileocecal valve or of the jejunum. Of the 17 pts with known CD, 12 (71%) showed signs of endoscopic involvement. Five pts (29%) had no evidence of SB involvement. Four pts with known CD additionally had jejunal or ileal stenosis or jejuno-colonic fistulas. In two pts endoscopic treatment of a jejunal and an ileal stenosis by balloon-dilation resulted in a partial remission of symptoms, one pt with an ileal stenosis was referred to surgery. Conclusions: DBE detected active mucosal SB disease in half of the pts with
www.giejournal.org
suspected CD and 70% of pts with clinically confirmed CD and thus represents a valuable diagnostic tool for SB CD. Endoscopic treatment of stricturizing CD by balloon-dilation seems to be useful but needs further investigation.
T1655 Observation and Treatment of Small Bowel Diseases Using Single Balloon Endoscope Kazuo Ohtsuka, Hiroshi Kashida, Kenta Kodama, Jun-Ichi Ukegawa, Hiroshi Kanie, Ken-Ichi Mizuno, Yui Kudo, Orie Takemura, Shin-Ei Kudo Backgrounds and aims: Recent advances in capsule endoscopy (CE) and double balloon endoscopy (DBE) have enabled an endoscopic approach to small bowel diseases. However, CE is simply a diagnostic tool and DBE is fairly complicated to handle. We developed a single balloon endoscopy (SBE) in cooperation with Olympus Medical Systems. The single balloon enteroscope consists of an endoscope and a splinting tube. In this system, a balloon is attached to the splinting tube, but not to the scope itself. We also used DBE. Here we evaluated the usefulness of SBE for the diagnosis and treatment in small intestinal diseases. Patients and methods: Patients were suspected of having small intestinal diseases after upper and lower gastrointestinal endoscopy. They consisted of 65 cases (16 women, 49 men; range 19-78 years old) that received a total of 102 examinations. Thirty-six cases showed symptoms of gastrointestinal tract bleeding, ten had obstruction, five had abdominal pain, five had enteritis, and five cases were for assessment of Crohn’s disease and four had tumors in the small intestine. We used Single Balloon Enteroscope SIF-Q260 (Olympus, Tokyo, Japan), that consists of the endoscope with working length of 2000 mm and an outer diameter of 9.2 mm and splinting tube with a balloon and an outer diameter of 13.2 mm for 79 examinations and DBE (EN-450P5, T5, Fujion, Tokyo, Japan) for 11 examinations. SBE was performed by single-person insertion method in most cases, though DBE needed two persons. Results: In twenty-one cases, the cause of bleeding was diagnosed as either an ulcer, angiodysplasia, Crohn’s disease, inflammatory polyp, or metastatic cancer, but in nine cases the cause was not identified. The ten obstruction cases were comprised of ulcers, adhesion, Crohn’s disease, jejunal volvulus, and malignant lymphoma. For treatment, clippings were performed for bleeding in six patients, polypectomy for two, reversal of volvulus for one, and balloon dilation for ilial stenosis in one. Examination time of anterograde insertion were 65.3 30.5 minutes for SBE and 74.0 26.9 minutes for DBE. That of retrograde insertion were 57.5 24.6 minutes for SBE and 56.3 24.4 minutes for DBE. No complications were encountered. Conclusion: The newly developed SBE has achieved high diagnostic yields with high quality images. It is easy to set up and to insert with single-person method. It is useful for the diagnosis and endoscopic treatment for small bowel diseases.
T1656 Small Intestinal Mucosal Breaks with Short-Term Administration of Non-Steroidal Anti-Inflammatory Drugs Katya Gudis, Shunji Fujimori, Yukie Yamada, Yoko Takahashi, Tsuguhiko Seo, Akihito Ehara, Tsuyoshi Kobayashi, Keigo Mitsui, Masaoki Yonezawa, Shu Tanaka, Atsushi Tatsuguchi, Choitsu Sakamoto Background & Aims: The concentrations of non-steroidal anti-inflammatory drugs (NSAIDs), bile acids, and intestinal flora in regions of the small intestine differ from other areas in the gastrointestinal tract. Thus, one may speculate that the effect of NSAIDs may also differ in the small intestinal mucosa. The aim of this study is to investigate the effect of short-term NSAID medication on the mucosa of the small intestine. Methods: We enrolled 76 healthy male volunteers between 20 to 45 years of age and with no history of surgery. All study subjects were first examined by baseline capsule endoscopy. We then randomly assigned 43 subjects to undertake a 14-day regimen of NSAID (diclofenac sodium, 25 mg; 3 times daily) medication with proton-pump inhibitors as gastroprotection (omeprazole, 20 mg; once daily). The remaining 33 subjects were channeled into a separate study. After 14 days, the 43 subjects all underwent post-treatment capsule endoscopy, and any mucosal breaks of the small intestine assessed and scored as follows: redness with obvious loss of villi, A; small aphtha, B; erosion, C; ulcer-like, D. The regions within which these lesions were located are expressed as the oral-side, mid-section and anal-side; with each division corresponding to 1/3 the transit time of the capsule endoscope in the small intestine. Results: Four subjects were excluded from analysis due to incomplete capsule endoscopy evaluations of the small intestine, two subjects at baseline and two at post-treatment capsule endoscopy. Baseline endoscopy revealed 27 mucosal breaks in 10 out of 74 subjects (14%), consisting of 4 lesions in the oral-side, 7 in the mid-section, and 16 in the anal-side of the small intestine. The proportion of type C and D lesions found in the anal-side (56%) was significantly higher than in the oral-side, where no such lesions were found (0%). Posttreatment endoscopy identified 140 mucosal breaks in 25 out of 41 subjects (61%) on NSAID medication, and consisted of 74 lesions in the oral-side, 34 in the midsection, and 32 in the anal-side. Thus, there was a significant increase in the number of lesions in the NSAID group, with a higher proportion of lesions located in the oral-side than in the anal-side. Type A lesions were more numerous in the oral-side (49 out of 74: 66%) than in the other two regions, with no significant difference between the number of C and D lesions in the oral (13) and anal (11)
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB271