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Tu1589 Small Bowel Tumors Not Seen At Capsule Endoscopy. Missed or Misdiagnosis? A Systematic Review
Abstracts
Lanza scale and evaluated image quality on a 10 point visual analogue score (VAS). Overall agreement and kappa value with bias corrected 95% confidence intervals using bootstrapping techniques were calculated to assess inter-observer reliability. Results: The inter-observer agreement () with HR-WLE among all 6 endoscopists was 0.62 (95% CI 0.52-0.72), which improved significantly with NBI to 0.76(95% CI 0.69-0.84, p⫽0.02). The inter-observer agreement among expert endoscopists with HR-WLE was “substantial” (⫽0.75, 95% CI 0.63-0.87) and improved with NBI to “almost perfect agreement (⫽ 0.87, 95% CI 0.78-0.95, p⫽0.06) which almost reached statistical significance. The inter-observer agreement among non-expert endoscopists with HR-WLE was “moderate” (⫽0.54, 95% CI 0.42-0.67) and significantly improved with NBI to “substantial” (⫽0.72, 95% CI 0.60-0.82, p⫽0.02). Non-expert endoscopists found significantly higher number of mucosal hemorrhages on NBI images (p⫽0.03). VAS scores for NBI images were higher than HR-WLE for experts while the opposite was true for non-experts. VAS scores for NBI images were however consistently higher than HR-WLE when the paired images were presented side by side. Conclusion: Inter-observer reliability between both expert and non-expert endoscopists for assessment of NSAID induced injury is better with NBI than HR-WLE images. NBI imaging improves the visualization of mucosal hemorrhages especially in non-expert endoscopists.
Tu1589 Small Bowel Tumors Not Seen At Capsule Endoscopy. Missed or Misdiagnosis? A Systematic Review Tee Joo Chua, Warwick Selby AW Morrow Institute of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia Introduction: Since the introduction of video capsule endoscopy(CE) in 2001, it has been used extensively in the imaging of the small bowel, particularly in diagnostic assessment of obscure gastrointestinal bleeding(OGIB), surveillance in polyposis syndromes and suspected or confirmed Crohn’s disease. Its diagnostic yield is equivalent to intra-operative enteroscopy and higher then radiological investigation.However, meta-analyses have shown that CE can have a significant miss rate of up to 13% in detecting mucosal lesions, particularly small bowel tumors. This study aims to review the literature on CE to determine the characteristics of the tumors missed by CE and the specific CE findings described.MethodsA review of the English language literature on CE and double or single balloon endoscopy where there were documented lesions missed by CE. A Pubmed, Embase and Ovid/Medline search was performed with the terms ‘capsule endoscopy’, ‘ double balloon endoscopy’ and ‘single balloon endoscopy’. The references of all papers which had missed lesions were further searched for relevant articles. Results Forty one patients with small bowel tumors missed by CE were identified from 11 studies. Thirty nine had undergone CE for investigation of OGIB and 2 were for polyp surveillance in Peutz-Jeghers syndrome.Twenty one patients had reportedly normal CE examinations, 15 others were reported as having blood in the small bowel lumen without a lesion seen and the remaining 5 had non-specific erythema or possible mucosal ulceration detected on CE (Table 1).Not all papers reviewed detailed location or histology of the missed tumors. Histology and polyp location were recorded in only 22 of 41 patients. In this group, the most commonly missed malignant small bowel tumors were GISTs (n⫽7) followed by adenocarcinoma of the small bowel (n⫽3). Of the missed small bowel tumors, 50% (11/22) were in the proximal small bowel with 91% (20/22) found before the ileum. This is consistent with some postulates that due to the curvature of the proximal small bowel coupled with the faster transit time in the proximal small bowel, there are ‘blind spots’ where CE is not able to image. The tumor type and location are detailed in Table 2. Conclusion CE may miss small bowel tumors but in only half the patients was the capsule study reported as truly normal. In the remainder either blood or non-specific findings were identified in the small bowel. The majority of missed tumors on CE are in the proximal small bowel. The rapid transit of the capsule through this area may explain why this is the case. Where the clinical index of suspicion is high, a negative or non-specific CE finding does not exclude a tumor in the proximal small bowel and an alternative diagnostic modality should be considered. Capsule findings where tumors were not seen at CE Capsule findings Completely normal Blood detected in lumen Non-specific findings Total
Numbers 21 15 5 41
Table 2. missed tumors and location in small bowel Tumor histology Gastrointestinal stromal tumors Small bowel adenocarcinoma Lipoma Lymphoma Carcinoid Hamartoma Metastasis to small bowel/ Others Total
Number
Duodenum
Proximal Jejunum
Jejunum
Ileum
7
1
4
2
0
3
2
1
0
0
3 2 1 2 4
0 0 0 0 1
1 0 1 0 0
1 2 0 1 3
1 0 0 1 0
22
4/22
7/22
9/22
2/22
Tu1590 Diabetes Mellitus, Insulin Resistance, Obesity and the Metabolic Syndrome Do Not Predict Delayed Transit At Capsule Endoscopy Milan S. Bassan1, Robert Cheng1, Nak-Jin Choi1, Suhirdan Vivekanandarajah1, Shehan I. Abey1,2, Jennifer A. McDonald1 1 Gastroenterology, Wollongong Hospital, Wollongong, NSW, Australia; 2 Wollongong Day Surgery, Wollongong, NSW, Australia Introduction: Capsule endoscopy (CE) is a powerful tool for assessing the small intestinal mucosa, however prolonged gastric or small intestinal transit may lead to an incomplete examination. Previous studies have been inconsistent in identifying factors predicting prolonged transit. This study examines clinical parameters as well as features of the metabolic syndrome as predictors of capsule transit time. Methods: All patients referred for CE who provided consent were recruited prospectively. CE was undertaken using our standard practice. Diabetics were given metoclopramide. Simple clinical parameters (age, height, weight, waist circumference and blood pressure), medications and co-morbidities were documented. Blood was collected for glucose, insulin, HbA1c and full lipid profile. The Metabolic Syndrome was defined using the International Diabetes Federation (2006) definition. CE findings, gastric transit (GT) and small intestinal transit (SIT) times were recorded. HOMA-IR was used to measure insulin resistance.Linear regression was used to test for the association between the outcome measures and recorded variables. Univariate analysis with T-testing was applied to each variable. A p-value of ⱕ 0.05 was considered significant. Results: 156 patients (86 female), mean age 63 years were recruited. The mean GT was 31.2 minutes (SD 30.4) and the mean SIT was 224.3 minutes (SD 88.8). There were 37 diabetics and 89 patients (57%) met the International Diabetes Federation definition of The Metabolic Syndrome.Six patients had an incomplete study for reasons including failure to exit the stomach, hold up in a duodenal diverticulum and incomplete small bowel transit during the battery life.Beta blockers reduced GT by 13.8 minutes (p ⫽ 0.03, 95% CI: 1.40 - 26.2). Increasing age also predicted decreased GT (p ⫽ 0.04). Diabetes, BMI, waist circumference, glucose and presence of the metabolic syndrome did not predict altered GT.Increasing blood glucose levels at the time of CE (regardless of diabetes status) predicted decreased SIT (p ⫽ 0.006). Patients with diabetes had reduced SIT by 34.5 minutes (p ⫽ 0.04; 95% CI: 1.5 - 67.5). There was a trend towards reduction in SIT with increasing BMI (p ⫽ 0.06).Insulin resistance, age, sex, the metabolic syndrome, medications or other co-morbid conditions did not predict SIT. None of the study variables predicted an incomplete capsule study. Conclusions: No factors (in particular, diabetes mellitus, obesity and the metabolic syndrome) were predictive of slower small intestinal transit times or of an incomplete study. Hyperglycaemia at the time of the procedure predicts faster small bowel transit time (p ⫽ 0.006) as does diabetes (p ⫽ 0.04). Decreased gastric transit time was seen in those on beta blocker therapy (p ⫽ 0.03) and with increasing age (p ⫽ 0.04).
Tu1591 Sensitivity Specificity and Diagnostic Yield of Capsule Endoscopy in Patients Undergoing Subsequent Double Balloon Enteroscopy David Tenembaum1, Cristina P. Sison2, Moshe Rubin1 1 Gastroenterology, New York Hospital Queens Weill-Cornell Medical College, Flushing, NY; 2Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, NY Introduction: Endoscopic evaluation of the small intestine can be performed by capsule endoscopy (CE) or double balloon enteroscopy (DBE). CE is non invasive, and is often performed initially. DBE enables careful inspection and therapeutic intervention but can be limited by incomplete small bowel visualization. Multiple studies have demonstrated similar overall diagnostic yield
AB456 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Lanza scale and evaluated image quality on a 10 point visual analogue score (VAS). Overall agreement and kappa value with bias corrected 95% confidence intervals using bootstrapping techniques were calculated to assess inter-observer reliability. Results: The inter-observer agreement () with HR-WLE among all 6 endoscopists was 0.62 (95% CI 0.52-0.72), which improved significantly with NBI to 0.76(95% CI 0.69-0.84, p⫽0.02). The inter-observer agreement among expert endoscopists with HR-WLE was “substantial” (⫽0.75, 95% CI 0.63-0.87) and improved with NBI to “almost perfect agreement (⫽ 0.87, 95% CI 0.78-0.95, p⫽0.06) which almost reached statistical significance. The inter-observer agreement among non-expert endoscopists with HR-WLE was “moderate” (⫽0.54, 95% CI 0.42-0.67) and significantly improved with NBI to “substantial” (⫽0.72, 95% CI 0.60-0.82, p⫽0.02). Non-expert endoscopists found significantly higher number of mucosal hemorrhages on NBI images (p⫽0.03). VAS scores for NBI images were higher than HR-WLE for experts while the opposite was true for non-experts. VAS scores for NBI images were however consistently higher than HR-WLE when the paired images were presented side by side. Conclusion: Inter-observer reliability between both expert and non-expert endoscopists for assessment of NSAID induced injury is better with NBI than HR-WLE images. NBI imaging improves the visualization of mucosal hemorrhages especially in non-expert endoscopists.
Tu1589 Small Bowel Tumors Not Seen At Capsule Endoscopy. Missed or Misdiagnosis? A Systematic Review Tee Joo Chua, Warwick Selby AW Morrow Institute of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia Introduction: Since the introduction of video capsule endoscopy(CE) in 2001, it has been used extensively in the imaging of the small bowel, particularly in diagnostic assessment of obscure gastrointestinal bleeding(OGIB), surveillance in polyposis syndromes and suspected or confirmed Crohn’s disease. Its diagnostic yield is equivalent to intra-operative enteroscopy and higher then radiological investigation.However, meta-analyses have shown that CE can have a significant miss rate of up to 13% in detecting mucosal lesions, particularly small bowel tumors. This study aims to review the literature on CE to determine the characteristics of the tumors missed by CE and the specific CE findings described.MethodsA review of the English language literature on CE and double or single balloon endoscopy where there were documented lesions missed by CE. A Pubmed, Embase and Ovid/Medline search was performed with the terms ‘capsule endoscopy’, ‘ double balloon endoscopy’ and ‘single balloon endoscopy’. The references of all papers which had missed lesions were further searched for relevant articles. Results Forty one patients with small bowel tumors missed by CE were identified from 11 studies. Thirty nine had undergone CE for investigation of OGIB and 2 were for polyp surveillance in Peutz-Jeghers syndrome.Twenty one patients had reportedly normal CE examinations, 15 others were reported as having blood in the small bowel lumen without a lesion seen and the remaining 5 had non-specific erythema or possible mucosal ulceration detected on CE (Table 1).Not all papers reviewed detailed location or histology of the missed tumors. Histology and polyp location were recorded in only 22 of 41 patients. In this group, the most commonly missed malignant small bowel tumors were GISTs (n⫽7) followed by adenocarcinoma of the small bowel (n⫽3). Of the missed small bowel tumors, 50% (11/22) were in the proximal small bowel with 91% (20/22) found before the ileum. This is consistent with some postulates that due to the curvature of the proximal small bowel coupled with the faster transit time in the proximal small bowel, there are ‘blind spots’ where CE is not able to image. The tumor type and location are detailed in Table 2. Conclusion CE may miss small bowel tumors but in only half the patients was the capsule study reported as truly normal. In the remainder either blood or non-specific findings were identified in the small bowel. The majority of missed tumors on CE are in the proximal small bowel. The rapid transit of the capsule through this area may explain why this is the case. Where the clinical index of suspicion is high, a negative or non-specific CE finding does not exclude a tumor in the proximal small bowel and an alternative diagnostic modality should be considered. Capsule findings where tumors were not seen at CE Capsule findings Completely normal Blood detected in lumen Non-specific findings Total
Numbers 21 15 5 41
Table 2. missed tumors and location in small bowel Tumor histology Gastrointestinal stromal tumors Small bowel adenocarcinoma Lipoma Lymphoma Carcinoid Hamartoma Metastasis to small bowel/ Others Total
Number
Duodenum
Proximal Jejunum
Jejunum
Ileum
7
1
4
2
0
3
2
1
0
0
3 2 1 2 4
0 0 0 0 1
1 0 1 0 0
1 2 0 1 3
1 0 0 1 0
22
4/22
7/22
9/22
2/22
Tu1590 Diabetes Mellitus, Insulin Resistance, Obesity and the Metabolic Syndrome Do Not Predict Delayed Transit At Capsule Endoscopy Milan S. Bassan1, Robert Cheng1, Nak-Jin Choi1, Suhirdan Vivekanandarajah1, Shehan I. Abey1,2, Jennifer A. McDonald1 1 Gastroenterology, Wollongong Hospital, Wollongong, NSW, Australia; 2 Wollongong Day Surgery, Wollongong, NSW, Australia Introduction: Capsule endoscopy (CE) is a powerful tool for assessing the small intestinal mucosa, however prolonged gastric or small intestinal transit may lead to an incomplete examination. Previous studies have been inconsistent in identifying factors predicting prolonged transit. This study examines clinical parameters as well as features of the metabolic syndrome as predictors of capsule transit time. Methods: All patients referred for CE who provided consent were recruited prospectively. CE was undertaken using our standard practice. Diabetics were given metoclopramide. Simple clinical parameters (age, height, weight, waist circumference and blood pressure), medications and co-morbidities were documented. Blood was collected for glucose, insulin, HbA1c and full lipid profile. The Metabolic Syndrome was defined using the International Diabetes Federation (2006) definition. CE findings, gastric transit (GT) and small intestinal transit (SIT) times were recorded. HOMA-IR was used to measure insulin resistance.Linear regression was used to test for the association between the outcome measures and recorded variables. Univariate analysis with T-testing was applied to each variable. A p-value of ⱕ 0.05 was considered significant. Results: 156 patients (86 female), mean age 63 years were recruited. The mean GT was 31.2 minutes (SD 30.4) and the mean SIT was 224.3 minutes (SD 88.8). There were 37 diabetics and 89 patients (57%) met the International Diabetes Federation definition of The Metabolic Syndrome.Six patients had an incomplete study for reasons including failure to exit the stomach, hold up in a duodenal diverticulum and incomplete small bowel transit during the battery life.Beta blockers reduced GT by 13.8 minutes (p ⫽ 0.03, 95% CI: 1.40 - 26.2). Increasing age also predicted decreased GT (p ⫽ 0.04). Diabetes, BMI, waist circumference, glucose and presence of the metabolic syndrome did not predict altered GT.Increasing blood glucose levels at the time of CE (regardless of diabetes status) predicted decreased SIT (p ⫽ 0.006). Patients with diabetes had reduced SIT by 34.5 minutes (p ⫽ 0.04; 95% CI: 1.5 - 67.5). There was a trend towards reduction in SIT with increasing BMI (p ⫽ 0.06).Insulin resistance, age, sex, the metabolic syndrome, medications or other co-morbid conditions did not predict SIT. None of the study variables predicted an incomplete capsule study. Conclusions: No factors (in particular, diabetes mellitus, obesity and the metabolic syndrome) were predictive of slower small intestinal transit times or of an incomplete study. Hyperglycaemia at the time of the procedure predicts faster small bowel transit time (p ⫽ 0.006) as does diabetes (p ⫽ 0.04). Decreased gastric transit time was seen in those on beta blocker therapy (p ⫽ 0.03) and with increasing age (p ⫽ 0.04).
Tu1591 Sensitivity Specificity and Diagnostic Yield of Capsule Endoscopy in Patients Undergoing Subsequent Double Balloon Enteroscopy David Tenembaum1, Cristina P. Sison2, Moshe Rubin1 1 Gastroenterology, New York Hospital Queens Weill-Cornell Medical College, Flushing, NY; 2Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, NY Introduction: Endoscopic evaluation of the small intestine can be performed by capsule endoscopy (CE) or double balloon enteroscopy (DBE). CE is non invasive, and is often performed initially. DBE enables careful inspection and therapeutic intervention but can be limited by incomplete small bowel visualization. Multiple studies have demonstrated similar overall diagnostic yield
AB456 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org