- Email: [email protected]
Tu1605 Small Bowel Capsule Endoscopy Findings in Enteropathy Associated With Common Variable Immunodeficiency Disorder (CVID)
Abstracts
women), including 10 duodenal NETs and 13 NETs elsewhere in the small intestine. Of these 13, all had ileal NETs on initial diagnosis; one patient who initially had only an ileal NET was found to have multiple jejunal and ileal recurrences 1 year following resection of the ileal primary. 9/23 patients were referred for bleeding from a suspected small bowel source. Other indications included abnormal video capsule endoscopy (4), duodenal nodule on outside endoscopy (6), and symptoms of carcinoid syndrome (4). 6/23 (26%) patients had multifocal NETs, and 3/23 patients had extraintestinal metastases at the time of diagnosis. Duodenal NETs appeared as submucosal nodules; sizes ranged from 0.5-1.5cm. These were treated successfully with endoscopic mucosal resection (EMR) in 9/10 (90%). 1 duodenal NET was treated with partial duodenectomy due to involvement of the muscularis propria. Of the 13 patients with ileal NETs, eight (62%) underwent surgical resection. 3 (23%) were treated with octreotide, and follow up data were not available in 2 (15%) Discussion: In our series duodenal NETS were successfully treated with EMR in 90% of cases. Surgery was required for one duodenal NET due to involvement of the muscularis propria on EUS. 6/23 patients (26%) with SI-NET had multifocal SINETs, including one patient with multifocal duodenal NETs. This incidence of multifocal disease is consistent with prior reports. We therefore recommend evaluation of the entire SI for patients diagnosed with a SI-NET, particularly patients with ileal NETs. The need for complete SI evaluation in patients with duodenal NETs remains uncertain; complete small bowel imaging was not performed routinely in these patients, thus we could not define the incidence of synchronous jejunal or ileal NETs.
Tu1602 A Comparison of the Yield of Spiral Enteroscopy to Wireless Capsule Endoscopy Findings: Report From a UK Centre Elizabeth A. Arthurs, Peter Marden, Stephen Hughes Gastroenterology, North Bristol NHS Trust, Bristol, United Kingdom Background: Spiral enteroscopy (SE) is used to evaluate and treat lesions affecting the small intestine. Abnormalities are often initially found using other diagnostic tools such as radiological imaging and wireless capsule endoscopy (WCE). There is little published data evaluating the findings of SE in patients with abnormalities seen at prior capsule endoscopy. Aims: To evaluate the diagnostic yield of spiral enteroscopy and compare findings in patients who had previously had wireless capsule endoscopy in a single UK centre. Methods: A retrospective analysis of case notes of all patients undergoing WCE followed by SE was performed. Data regarding patient demographics, indications for WCE, WCE findings, subsequent SE findings and therapy performed was collected and analysed. Results: Twenty two patients had capsule endoscopies followed by SE. Two patients had repeat WCE and 2 had SE twice. SE was performed orally on 23 occasions and once per rectum. There were 17 male and 7 female patients. Mean age was 70.6 (range 40 - 90). Indications for WCE were recurrent iron deficiency anaemia (11), gastrointestinal bleeding/melaena (5), occult gastrointestinal bleeding (5), anaemia and abdominal pain (2), and abdominal pain (1). Findings on WCE included angiodysplasia (9), normal examination (6), ulceration (3), small bowel diverticula (2), polyps (2), ulceration (2), findings suspicious for angiodysplasia (2), strictures (1) and nodular lymphoid hyperplasia (1). 2 patients had more than one abnormality identified. The mean time from WCE to SE was 190.9 days (range 28 - 850). All SEs were performed under conscious sedation. The estimated depth of insertion was available for 20 patients, with a mean of 215.2 cm (range 100 - 300 cm) per oral, and 50 cm from the ICV per rectum. Mean time for the procedure in 20 patients was 40.5 mins (range 25 - 65). Abnormalities were found by SE in 14 (70%) cases. Findings on WCE were reproduced at SE in 19 cases (79.2%). In 3 cases, SE found additional pathology not seen at WCE (2 angiodysplasia, 1 jejunal diverticulae). In 2 cases SE clarified suspicious but non diagnostic abnormalities seen at WCE (angiodysplasia) and in 2 cases of small bowel polyps seen at WCE, SE confirmed a diagnosis of polypoid lymphangiectases. Thirteen cases (54.2%) underwent therapy in the form of APC with complete haemostasis in all. Conclusions: In our experience, SE is able to locate pathology found on WCE in 79.2% of cases, but it may also find additional pathology and clarify non diagnostic findings. SE also permits therapy and complements WCE in the management of patients with suspected small bowel pathology.
Tu1603 Safety and Efficacy of Gastroenterologist Administered Moderation Sedation in Patients Undergoing Spiral Enteroscopy Mariam Naveed1, Svetang V. Desai2, Alison Jazwinski2, Daniel Wild2 1 Internal Medicine, Duke University Medical Center, Durham, NC; 2 Gastroenterology, Duke University Medical Center, Durham, NC Background: Initial published data on spiral enteroscopy featured patients who were sedated with general anesthesia (GA) or monitored anesthesia care (MAC). Recent studies and our experience have shown that this procedure can be performed with moderate sedation. Objectives:The aim of this retrospective study is to demonstrate that spiral enteroscopy with moderate sedation is feasible, safe,
and effective with reasonable recovery time and minimal side effects. Patient and Methods:Using an electronic medical record, we identified 44 consecutive patients who underwent spiral enteroscopy at Duke University Medical Center between June 1, 2009 and July 31, 2010, for investigation of the small bowel. The patients’ average age was 57.4, average BMI was 28.9, and an average ASA score of 2.All patients had procedures completed with either the Endo-Ease Discovery SB or Vista overtubes produced by Spirus Medical. Results: Of the 44 cases, 30 were anterograde (68%) and 14 were retrograde (32%). 75% of the patients had spiral endoscopy for obscure GI bleeding. Of the 30 patients who underwent anterograde evaluation, 67% were completed with moderate sedation. All but one of the 14 retrograde patients were completed with moderate sedation. Mean procedure time was shorter in patients who underwent moderate sedation vs. GA for both the anterograde 52 min vs. 63 min (p⫽0.172) and retrograde (63 min vs. 75 min) approach. Mean recovery time was shorter in patients who received moderate sedation vs. GA for both anterograde 62 min vs. 106 min (p⫽0.08) and retrograde (50 min vs. 85 min.) procedures. The depth of insertion was not significantly different (p⫽0.379) between the moderate sedation and GA groups for either the anterograde or retrograde approach.Complications were rare in both groups. There were a total of 4 minor complications, all in patients undergoing anterograde procedures. The group who received moderation sedation had one procedure-related sore throat and 2 sedation-related events, transient hypoxia and bradycardia. One patient who received general anesthesia had procedure-related abdominal pain requiring overnight observation. Conclusions: Our study demonstrates that spiral enteroscopy can safely and effectively be performed with moderate sedation. When comparing to general anesthesia, using moderate sedation for these procedures can mean shorter procedure and recovery times with similar low complication rates and depth of insertion.
Tu1604 The Efficacy of Uncovered Metallic Stent As a First-Line Therapy for the Malignant Duodenal Obstruction Hyung Su Ahn1, Su Jin Hong1, Jong Ho Moon1, Bong Min Ko1, Hyun Jong Choi1, Jae Pil Han1, Seung Hyo Han1, Won Young Cho2, Joo Young Cho2, Joon Seong Lee2, Moon Sung Lee1 1 Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Republic of Korea; 2Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Seoul, Republic of Korea Aims: The aim of this study was to report our experience about the treatment outcomes and complications of uncovered metallic stent as a first-line therapy for the inoperable malignant duodenal obstruction in a single tertiary center. Methods: A retrospective analysis was performed in 37 patients who had undergone placement of an uncovered metallic stent as a first-line therapy for the inoperable malignant duodenal obstruction from August 2001 to May 2010. We investigated the treatment outcomes and complications of the procedure. Results: A total of 37 patients (19 men and 18 women, mean age 63 years) underwent the procedures. The sites of obstruction were 9 in bulb, 18 in 2nd portion of duodenum, 7 in 3rd portion, 1 in 4th portion, and 2 in bulb and 2nd portion. The initial technical success rate was 91.9% (34/37), and the clinical success rate was 86.5% (32/37). Three patients with failure of stent placement were caused by insufficient stent expansion within 3 days after stent insertion. Two patients were recovered using balloon dilatation and an additional covered metallic stent insertion, respectively. Seven early complications occurred: 2 (5.4%) guirewire-induced micro-perforation and 5 (13.5%) pancreatitis. All of the guidewire-induced micro-perforation and pancreatitis were recovered with conservative treatment. During the follow-up, 5 patients had late complications needed the additional procedures: 4 stent occlusions due to tumor ingrowth and 1 stent migration. The mean duration without symptoms in the 5 patients was 125.2 days (range 51⬃216 days). Three stent occlusions were managed by placement of an additional covered stent and remaining one was treated by balloon dilatation. One stent migration was managed by placement of an additional covered stent. The median stent patency period and median survival period after stent insertion were 65 days and 214 days, respectively. There was no procedure-related death. Conclusions: We think that the uncovered metallic stent is effective as a first-line therapy for the inoperable malignant duodenal obstruction. Also, complications such as stent occlusion or migration can be easily managed with an additional covered metallic stent.
Tu1605 Small Bowel Capsule Endoscopy Findings in Enteropathy Associated With Common Variable Immunodeficiency Disorder (CVID) Laura Marelli, Darren Arokianathan, Linda Jackson, Hansa Palmer, Christos Toumpanakis, Owen Epstein, Ronnie Chee Royal Free Hospital, London, United Kingdom Introduction: Diarrhoea among patients with CVID is common. Abnormalities of villous architecture, giardia or campylobacter infection, small bowel bacterial
AB460 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Abstracts
overgrowth and microscopic colitis are seen frequently. The histopathological features of the enteropathy associated with CVID are not clear, and possible relationships with other causes of enteropathy remain debated. Capsule endoscopy (CE) is a new technique to demonstrate small bowel disease. Previous studies of CE with CVID are limited to ⬍4 cases, and the main finding is nodular lymphoid hyperplasia.Aim: To describe small bowel lesions found at CE in patients symptomatic with CVID enteropathy and to correlate this finding with histology. Methods: Between January 2009 and November 2010, we identify 6 patients (median age 41 years (range: 18-72); M/F: 5/1) with CVID who underwent CE in our unit for chronic diarrhea. They had gastroscopy and colonoscopy with biopsy prior to CE. We reviewed all CE imaging. Relevant information regarding medications, infections and histology were collected from medical records. Results: We performed CE in 6 CVID patients with diarrhoea (in 5 patients stool culture and duodenal biopsy were negative for infection, 1 had giardia treated successfully with tinidazole prior to CE). CE showed villous blunting, coeliac-like atrophy and aphtous ulcers throughout the small bowel in 2 patients; they were on immunoglobulins and not on NSAIDs. The second patient had recently been treated for giardia infection. On small bowel histology, the first patient showed diffuse B cell lymphoma and the other villous atrophy, increased intestinal intraepithelial lymphocytes and lack of plasma cells suggestive of CVID-related enteropathy. The third patient had evidence of villous atrophy without ulcers on CE. He was receiving steroids and infliximab. His histology had the 3 features of CVID enteropathy described earlier. The next 3 patients had terminal ileal erythema, normal small bowel (on steroids) and a nodular terminal ileum respectively on CE with normal histology. Conclusion: Using CE technology, we describe the macroscopic appearance of CVID-related enteropathy (confirmed on histology) as the presence of villous atrophy mimicking coeliac disease, and commonly apthous ulcers mimicking Crohn’s disease, in the small bowel. These lesions might be unique to CVID enteropathy, and different from other known enteropathy. CE is an effective way to assess small bowel involvement in CVID patients, but correlation with histology remains adamant, especially to exclude lymphoma and infection. Further studies with larger series of patients on the use of CE in CVID are ongoing; correlation with steroid and biologic treatment is important.
Tu1607 A Single Center Case Series of Antegrade Spiral Enteroscopy Procedures Nisha Patel, Rome Jutabha Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, CA Background: The use of spiral enteroscopy is rising. However, comprehensive deep enteroscopy evaluations that include spiral enteroscopy procedures is limited.Objective: Our aim in this case series is to evaluate the diagnostic yield and direct complications of antegrade spiral enteroscopy procedures.Design: Retrospective analysis.Setting: Tertiary-care referral center.Patients/Interventions: Consecutive antegrade spiral enteroscopy procedures performed at a single center by the same endoscopist from January 2009 to July 2010.Main outcome measurements: Indications, interventions, complications, depths of maximal insertion, lengths of procedure, diagnostic yield and failure rate. Results: During the study period, 42 patients underwent 47 spiral enteroscopy procedures. The average age of patients undergoing the procedure was 66 years. Two-thirds of the cases had prior intra-abdominal surgeries. The most common indications for enteroscopy were gastrointestinal bleeding and anemia. Hemostatic procedures were performed in 53% of cases. No short term complications from spiral enteroscopy or sedation were observed. Depth of maximal insertion beyond the ligament of Treitz was estimated at 308 centimeters reaching the distal jejunumproximal ileum. The average length of the procedures was 62 minutes. Diagnostic yield was 60% overall. One case was unsuccessful due to altered anatomy from multiple gastrointestinal procedures including Roux-en-Y. Limitations: Single tertiary-care center. No long term complications or outcomes followed. Conclusions: Spiral enteroscopy procedures are not inferior to other forms of deep enteroscopy and are well tolerated by patients, including elderly patients with multiple co-morbidities. Spiral enteroscopy has comparable diagnostic yield, low failure rate and few complications.
Tu1606 Reducing Capsule Endoscopy Reading Times: Efficacy of New Playback Functions Venkataraman Subramanian, Jayan Mannath, Emmanouil Telakis, Krish Ragunath, Chris J. Hawkey Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, United Kingdom
Tu1608 Wireless Capsule Endoscopy in Patients With Implantable Cardiac Devices Jason Korenblit1, Yaa Oppong2, Laura Setlur2, Himanshu Bhayana1, Jonathan P. Logue3, Michael Dimarino1, Anthony Infantolino1, Mitchell Conn1 1 Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA; 2Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA; 3Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA
Introduction: Capsule endoscopy (CE) has proven to be a valuable tool in the evaluation of obscure GI bleeding, suspected Crohn’s disease, coeliac disease and polyposis syndromes. The reading time and interpretation of video capsule data is very time consuming given that, in total, more than 50,000 images have to be reviewed. Recently, Olympus capsule endoscopy software systems have been equipped with auto-speed adjusted, express view and overview functions. The aim of this study was to evaluate the new functions by analyzing the diagnostic yield of CE and the reading time of the new playback features by comparing it with conventional analyzing systems. Methods: Data on 42 patients who underwent CE were obtained, and two experienced CE readers (⬎100 cases) analyzed the CE images independently using either the overview with express selected function or the overview with auto-speed adjusted function respectively. All CE videos were read blinded at 15 frames per second using the two new functions. The diagnostic yield was then compared to the conventionally read CE findings. All CE recording were done using the Olympus (Keymed UK) capsule endoscopy systems and read using the Olympus EndoCapsule software package. Results: 42 patients (20male, 22 female) with a mean age of 49.3(⫾21.2) years were included in the study. Clinically significant findings were found in 24/42 (60%) of patients. Using overview functions alone would have resulted in missing 6/24 (25%) clinically significant findings, while both express selected and auto-speed adjusted methods missed 1/24 (4%) clinically significant findings each. The average reading time for the auto-speed function plus overview was 35(⫾10) minutes and was significantly (p⫽0.01) more than that for express selected plus overview which was 20(⫾5) minutes. If the CE videos were read conventionally at 15 frames per second the average reading time based on the length of the recording would have been 47 (⫾14) minutes. Conclusions: The diagnostic miss rate was high when overview functions alone were used. There was no significant difference in positive findings between auto-speed adjusted and express selected functions when used along with overview functions and the reading time using the new systems was significantly shorter than the conventional system. The new playback systems can efficaciously reduce reading times of CE with the express selected function reducing readings time significantly more than the auto-speed adjusted function.
Background: Wireless capsule endoscopy is a valuable tool for non-invasive diagnostic imaging of the deep gastrointestinal tract. Implantable cardiac devices such as pacemakers and automated implantable cardiac defibrillators (AICD) are sensitive to electromagnetic interference and imaging in these high-risk patients must be undertaken with caution. The presence of these devices is a relative contraindication for use of capsule endoscopy and there is limited safety data available. Since 2001, our institution has completed over 3500 capsule endoscopies and we are reporting our experience with capsule endoscopy in patients with implantable cardiac devices. Methods: This was a retrospectively review from January 2002 through August 2010 at a single tiertiary care center. Twenty- nine patients in our database had implantable cardiac devices and underwent capsule endoscopy, 22 with pacemakers, 3 with an implantable AICD, and 4 with a combined AICD/pacemaker. Age, sex, medications, comorbidities, primary and secondary indication for the study, and capsule findings were reviewed from charts and the capsule endoscopy computer reporting system. Capsules were read by expert endoscopists with several years of experience. Patients were monitored in the office setting during their capsule endoscopies to assess for adverse events. Results: The mean age of the subjects with pacemakers was 75.08 years (46.34 years - 92.34 years), with pure AICD’s was 75.33 years (68.72 years ⫺79.56 years), and with combination devices was 82.31 years (69.85 years - 92.16 years). 10 (34%) studies were done in females and 19 (66%) in males. The primary or secondary indication was for obscure gastrointestinal bleeding in 28 (97%) of the studies. Other indications included iron deficiency anemia in 6 (21%), abdominal pain in 1 (3%) and abnormal imaging in 1 (3%). Studies done for obscure gastrointestinal bleed revealed a finding that explained the bleeding in 61%. The overall diagnostic yield for any finding was 62%. The cecum was reached successfully in 90% of studies. There were no adverse events reported during the capsule procedure. Conclusion: Although caution should be exercised in patients with implantable cardiac devices during wireless capsule endoscopy, our single center experience thus far showed no adverse events during the capsule study. Diagnostic yield was in keeping with that reported in prior literature. The most common indication for the study was for obscure gastrointestinal bleed.
www.giejournal.org
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB461
women), including 10 duodenal NETs and 13 NETs elsewhere in the small intestine. Of these 13, all had ileal NETs on initial diagnosis; one patient who initially had only an ileal NET was found to have multiple jejunal and ileal recurrences 1 year following resection of the ileal primary. 9/23 patients were referred for bleeding from a suspected small bowel source. Other indications included abnormal video capsule endoscopy (4), duodenal nodule on outside endoscopy (6), and symptoms of carcinoid syndrome (4). 6/23 (26%) patients had multifocal NETs, and 3/23 patients had extraintestinal metastases at the time of diagnosis. Duodenal NETs appeared as submucosal nodules; sizes ranged from 0.5-1.5cm. These were treated successfully with endoscopic mucosal resection (EMR) in 9/10 (90%). 1 duodenal NET was treated with partial duodenectomy due to involvement of the muscularis propria. Of the 13 patients with ileal NETs, eight (62%) underwent surgical resection. 3 (23%) were treated with octreotide, and follow up data were not available in 2 (15%) Discussion: In our series duodenal NETS were successfully treated with EMR in 90% of cases. Surgery was required for one duodenal NET due to involvement of the muscularis propria on EUS. 6/23 patients (26%) with SI-NET had multifocal SINETs, including one patient with multifocal duodenal NETs. This incidence of multifocal disease is consistent with prior reports. We therefore recommend evaluation of the entire SI for patients diagnosed with a SI-NET, particularly patients with ileal NETs. The need for complete SI evaluation in patients with duodenal NETs remains uncertain; complete small bowel imaging was not performed routinely in these patients, thus we could not define the incidence of synchronous jejunal or ileal NETs.
Tu1602 A Comparison of the Yield of Spiral Enteroscopy to Wireless Capsule Endoscopy Findings: Report From a UK Centre Elizabeth A. Arthurs, Peter Marden, Stephen Hughes Gastroenterology, North Bristol NHS Trust, Bristol, United Kingdom Background: Spiral enteroscopy (SE) is used to evaluate and treat lesions affecting the small intestine. Abnormalities are often initially found using other diagnostic tools such as radiological imaging and wireless capsule endoscopy (WCE). There is little published data evaluating the findings of SE in patients with abnormalities seen at prior capsule endoscopy. Aims: To evaluate the diagnostic yield of spiral enteroscopy and compare findings in patients who had previously had wireless capsule endoscopy in a single UK centre. Methods: A retrospective analysis of case notes of all patients undergoing WCE followed by SE was performed. Data regarding patient demographics, indications for WCE, WCE findings, subsequent SE findings and therapy performed was collected and analysed. Results: Twenty two patients had capsule endoscopies followed by SE. Two patients had repeat WCE and 2 had SE twice. SE was performed orally on 23 occasions and once per rectum. There were 17 male and 7 female patients. Mean age was 70.6 (range 40 - 90). Indications for WCE were recurrent iron deficiency anaemia (11), gastrointestinal bleeding/melaena (5), occult gastrointestinal bleeding (5), anaemia and abdominal pain (2), and abdominal pain (1). Findings on WCE included angiodysplasia (9), normal examination (6), ulceration (3), small bowel diverticula (2), polyps (2), ulceration (2), findings suspicious for angiodysplasia (2), strictures (1) and nodular lymphoid hyperplasia (1). 2 patients had more than one abnormality identified. The mean time from WCE to SE was 190.9 days (range 28 - 850). All SEs were performed under conscious sedation. The estimated depth of insertion was available for 20 patients, with a mean of 215.2 cm (range 100 - 300 cm) per oral, and 50 cm from the ICV per rectum. Mean time for the procedure in 20 patients was 40.5 mins (range 25 - 65). Abnormalities were found by SE in 14 (70%) cases. Findings on WCE were reproduced at SE in 19 cases (79.2%). In 3 cases, SE found additional pathology not seen at WCE (2 angiodysplasia, 1 jejunal diverticulae). In 2 cases SE clarified suspicious but non diagnostic abnormalities seen at WCE (angiodysplasia) and in 2 cases of small bowel polyps seen at WCE, SE confirmed a diagnosis of polypoid lymphangiectases. Thirteen cases (54.2%) underwent therapy in the form of APC with complete haemostasis in all. Conclusions: In our experience, SE is able to locate pathology found on WCE in 79.2% of cases, but it may also find additional pathology and clarify non diagnostic findings. SE also permits therapy and complements WCE in the management of patients with suspected small bowel pathology.
Tu1603 Safety and Efficacy of Gastroenterologist Administered Moderation Sedation in Patients Undergoing Spiral Enteroscopy Mariam Naveed1, Svetang V. Desai2, Alison Jazwinski2, Daniel Wild2 1 Internal Medicine, Duke University Medical Center, Durham, NC; 2 Gastroenterology, Duke University Medical Center, Durham, NC Background: Initial published data on spiral enteroscopy featured patients who were sedated with general anesthesia (GA) or monitored anesthesia care (MAC). Recent studies and our experience have shown that this procedure can be performed with moderate sedation. Objectives:The aim of this retrospective study is to demonstrate that spiral enteroscopy with moderate sedation is feasible, safe,
and effective with reasonable recovery time and minimal side effects. Patient and Methods:Using an electronic medical record, we identified 44 consecutive patients who underwent spiral enteroscopy at Duke University Medical Center between June 1, 2009 and July 31, 2010, for investigation of the small bowel. The patients’ average age was 57.4, average BMI was 28.9, and an average ASA score of 2.All patients had procedures completed with either the Endo-Ease Discovery SB or Vista overtubes produced by Spirus Medical. Results: Of the 44 cases, 30 were anterograde (68%) and 14 were retrograde (32%). 75% of the patients had spiral endoscopy for obscure GI bleeding. Of the 30 patients who underwent anterograde evaluation, 67% were completed with moderate sedation. All but one of the 14 retrograde patients were completed with moderate sedation. Mean procedure time was shorter in patients who underwent moderate sedation vs. GA for both the anterograde 52 min vs. 63 min (p⫽0.172) and retrograde (63 min vs. 75 min) approach. Mean recovery time was shorter in patients who received moderate sedation vs. GA for both anterograde 62 min vs. 106 min (p⫽0.08) and retrograde (50 min vs. 85 min.) procedures. The depth of insertion was not significantly different (p⫽0.379) between the moderate sedation and GA groups for either the anterograde or retrograde approach.Complications were rare in both groups. There were a total of 4 minor complications, all in patients undergoing anterograde procedures. The group who received moderation sedation had one procedure-related sore throat and 2 sedation-related events, transient hypoxia and bradycardia. One patient who received general anesthesia had procedure-related abdominal pain requiring overnight observation. Conclusions: Our study demonstrates that spiral enteroscopy can safely and effectively be performed with moderate sedation. When comparing to general anesthesia, using moderate sedation for these procedures can mean shorter procedure and recovery times with similar low complication rates and depth of insertion.
Tu1604 The Efficacy of Uncovered Metallic Stent As a First-Line Therapy for the Malignant Duodenal Obstruction Hyung Su Ahn1, Su Jin Hong1, Jong Ho Moon1, Bong Min Ko1, Hyun Jong Choi1, Jae Pil Han1, Seung Hyo Han1, Won Young Cho2, Joo Young Cho2, Joon Seong Lee2, Moon Sung Lee1 1 Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Republic of Korea; 2Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Seoul, Republic of Korea Aims: The aim of this study was to report our experience about the treatment outcomes and complications of uncovered metallic stent as a first-line therapy for the inoperable malignant duodenal obstruction in a single tertiary center. Methods: A retrospective analysis was performed in 37 patients who had undergone placement of an uncovered metallic stent as a first-line therapy for the inoperable malignant duodenal obstruction from August 2001 to May 2010. We investigated the treatment outcomes and complications of the procedure. Results: A total of 37 patients (19 men and 18 women, mean age 63 years) underwent the procedures. The sites of obstruction were 9 in bulb, 18 in 2nd portion of duodenum, 7 in 3rd portion, 1 in 4th portion, and 2 in bulb and 2nd portion. The initial technical success rate was 91.9% (34/37), and the clinical success rate was 86.5% (32/37). Three patients with failure of stent placement were caused by insufficient stent expansion within 3 days after stent insertion. Two patients were recovered using balloon dilatation and an additional covered metallic stent insertion, respectively. Seven early complications occurred: 2 (5.4%) guirewire-induced micro-perforation and 5 (13.5%) pancreatitis. All of the guidewire-induced micro-perforation and pancreatitis were recovered with conservative treatment. During the follow-up, 5 patients had late complications needed the additional procedures: 4 stent occlusions due to tumor ingrowth and 1 stent migration. The mean duration without symptoms in the 5 patients was 125.2 days (range 51⬃216 days). Three stent occlusions were managed by placement of an additional covered stent and remaining one was treated by balloon dilatation. One stent migration was managed by placement of an additional covered stent. The median stent patency period and median survival period after stent insertion were 65 days and 214 days, respectively. There was no procedure-related death. Conclusions: We think that the uncovered metallic stent is effective as a first-line therapy for the inoperable malignant duodenal obstruction. Also, complications such as stent occlusion or migration can be easily managed with an additional covered metallic stent.
Tu1605 Small Bowel Capsule Endoscopy Findings in Enteropathy Associated With Common Variable Immunodeficiency Disorder (CVID) Laura Marelli, Darren Arokianathan, Linda Jackson, Hansa Palmer, Christos Toumpanakis, Owen Epstein, Ronnie Chee Royal Free Hospital, London, United Kingdom Introduction: Diarrhoea among patients with CVID is common. Abnormalities of villous architecture, giardia or campylobacter infection, small bowel bacterial
AB460 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Abstracts
overgrowth and microscopic colitis are seen frequently. The histopathological features of the enteropathy associated with CVID are not clear, and possible relationships with other causes of enteropathy remain debated. Capsule endoscopy (CE) is a new technique to demonstrate small bowel disease. Previous studies of CE with CVID are limited to ⬍4 cases, and the main finding is nodular lymphoid hyperplasia.Aim: To describe small bowel lesions found at CE in patients symptomatic with CVID enteropathy and to correlate this finding with histology. Methods: Between January 2009 and November 2010, we identify 6 patients (median age 41 years (range: 18-72); M/F: 5/1) with CVID who underwent CE in our unit for chronic diarrhea. They had gastroscopy and colonoscopy with biopsy prior to CE. We reviewed all CE imaging. Relevant information regarding medications, infections and histology were collected from medical records. Results: We performed CE in 6 CVID patients with diarrhoea (in 5 patients stool culture and duodenal biopsy were negative for infection, 1 had giardia treated successfully with tinidazole prior to CE). CE showed villous blunting, coeliac-like atrophy and aphtous ulcers throughout the small bowel in 2 patients; they were on immunoglobulins and not on NSAIDs. The second patient had recently been treated for giardia infection. On small bowel histology, the first patient showed diffuse B cell lymphoma and the other villous atrophy, increased intestinal intraepithelial lymphocytes and lack of plasma cells suggestive of CVID-related enteropathy. The third patient had evidence of villous atrophy without ulcers on CE. He was receiving steroids and infliximab. His histology had the 3 features of CVID enteropathy described earlier. The next 3 patients had terminal ileal erythema, normal small bowel (on steroids) and a nodular terminal ileum respectively on CE with normal histology. Conclusion: Using CE technology, we describe the macroscopic appearance of CVID-related enteropathy (confirmed on histology) as the presence of villous atrophy mimicking coeliac disease, and commonly apthous ulcers mimicking Crohn’s disease, in the small bowel. These lesions might be unique to CVID enteropathy, and different from other known enteropathy. CE is an effective way to assess small bowel involvement in CVID patients, but correlation with histology remains adamant, especially to exclude lymphoma and infection. Further studies with larger series of patients on the use of CE in CVID are ongoing; correlation with steroid and biologic treatment is important.
Tu1607 A Single Center Case Series of Antegrade Spiral Enteroscopy Procedures Nisha Patel, Rome Jutabha Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, CA Background: The use of spiral enteroscopy is rising. However, comprehensive deep enteroscopy evaluations that include spiral enteroscopy procedures is limited.Objective: Our aim in this case series is to evaluate the diagnostic yield and direct complications of antegrade spiral enteroscopy procedures.Design: Retrospective analysis.Setting: Tertiary-care referral center.Patients/Interventions: Consecutive antegrade spiral enteroscopy procedures performed at a single center by the same endoscopist from January 2009 to July 2010.Main outcome measurements: Indications, interventions, complications, depths of maximal insertion, lengths of procedure, diagnostic yield and failure rate. Results: During the study period, 42 patients underwent 47 spiral enteroscopy procedures. The average age of patients undergoing the procedure was 66 years. Two-thirds of the cases had prior intra-abdominal surgeries. The most common indications for enteroscopy were gastrointestinal bleeding and anemia. Hemostatic procedures were performed in 53% of cases. No short term complications from spiral enteroscopy or sedation were observed. Depth of maximal insertion beyond the ligament of Treitz was estimated at 308 centimeters reaching the distal jejunumproximal ileum. The average length of the procedures was 62 minutes. Diagnostic yield was 60% overall. One case was unsuccessful due to altered anatomy from multiple gastrointestinal procedures including Roux-en-Y. Limitations: Single tertiary-care center. No long term complications or outcomes followed. Conclusions: Spiral enteroscopy procedures are not inferior to other forms of deep enteroscopy and are well tolerated by patients, including elderly patients with multiple co-morbidities. Spiral enteroscopy has comparable diagnostic yield, low failure rate and few complications.
Tu1606 Reducing Capsule Endoscopy Reading Times: Efficacy of New Playback Functions Venkataraman Subramanian, Jayan Mannath, Emmanouil Telakis, Krish Ragunath, Chris J. Hawkey Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, United Kingdom
Tu1608 Wireless Capsule Endoscopy in Patients With Implantable Cardiac Devices Jason Korenblit1, Yaa Oppong2, Laura Setlur2, Himanshu Bhayana1, Jonathan P. Logue3, Michael Dimarino1, Anthony Infantolino1, Mitchell Conn1 1 Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA; 2Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA; 3Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA
Introduction: Capsule endoscopy (CE) has proven to be a valuable tool in the evaluation of obscure GI bleeding, suspected Crohn’s disease, coeliac disease and polyposis syndromes. The reading time and interpretation of video capsule data is very time consuming given that, in total, more than 50,000 images have to be reviewed. Recently, Olympus capsule endoscopy software systems have been equipped with auto-speed adjusted, express view and overview functions. The aim of this study was to evaluate the new functions by analyzing the diagnostic yield of CE and the reading time of the new playback features by comparing it with conventional analyzing systems. Methods: Data on 42 patients who underwent CE were obtained, and two experienced CE readers (⬎100 cases) analyzed the CE images independently using either the overview with express selected function or the overview with auto-speed adjusted function respectively. All CE videos were read blinded at 15 frames per second using the two new functions. The diagnostic yield was then compared to the conventionally read CE findings. All CE recording were done using the Olympus (Keymed UK) capsule endoscopy systems and read using the Olympus EndoCapsule software package. Results: 42 patients (20male, 22 female) with a mean age of 49.3(⫾21.2) years were included in the study. Clinically significant findings were found in 24/42 (60%) of patients. Using overview functions alone would have resulted in missing 6/24 (25%) clinically significant findings, while both express selected and auto-speed adjusted methods missed 1/24 (4%) clinically significant findings each. The average reading time for the auto-speed function plus overview was 35(⫾10) minutes and was significantly (p⫽0.01) more than that for express selected plus overview which was 20(⫾5) minutes. If the CE videos were read conventionally at 15 frames per second the average reading time based on the length of the recording would have been 47 (⫾14) minutes. Conclusions: The diagnostic miss rate was high when overview functions alone were used. There was no significant difference in positive findings between auto-speed adjusted and express selected functions when used along with overview functions and the reading time using the new systems was significantly shorter than the conventional system. The new playback systems can efficaciously reduce reading times of CE with the express selected function reducing readings time significantly more than the auto-speed adjusted function.
Background: Wireless capsule endoscopy is a valuable tool for non-invasive diagnostic imaging of the deep gastrointestinal tract. Implantable cardiac devices such as pacemakers and automated implantable cardiac defibrillators (AICD) are sensitive to electromagnetic interference and imaging in these high-risk patients must be undertaken with caution. The presence of these devices is a relative contraindication for use of capsule endoscopy and there is limited safety data available. Since 2001, our institution has completed over 3500 capsule endoscopies and we are reporting our experience with capsule endoscopy in patients with implantable cardiac devices. Methods: This was a retrospectively review from January 2002 through August 2010 at a single tiertiary care center. Twenty- nine patients in our database had implantable cardiac devices and underwent capsule endoscopy, 22 with pacemakers, 3 with an implantable AICD, and 4 with a combined AICD/pacemaker. Age, sex, medications, comorbidities, primary and secondary indication for the study, and capsule findings were reviewed from charts and the capsule endoscopy computer reporting system. Capsules were read by expert endoscopists with several years of experience. Patients were monitored in the office setting during their capsule endoscopies to assess for adverse events. Results: The mean age of the subjects with pacemakers was 75.08 years (46.34 years - 92.34 years), with pure AICD’s was 75.33 years (68.72 years ⫺79.56 years), and with combination devices was 82.31 years (69.85 years - 92.16 years). 10 (34%) studies were done in females and 19 (66%) in males. The primary or secondary indication was for obscure gastrointestinal bleeding in 28 (97%) of the studies. Other indications included iron deficiency anemia in 6 (21%), abdominal pain in 1 (3%) and abnormal imaging in 1 (3%). Studies done for obscure gastrointestinal bleed revealed a finding that explained the bleeding in 61%. The overall diagnostic yield for any finding was 62%. The cecum was reached successfully in 90% of studies. There were no adverse events reported during the capsule procedure. Conclusion: Although caution should be exercised in patients with implantable cardiac devices during wireless capsule endoscopy, our single center experience thus far showed no adverse events during the capsule study. Diagnostic yield was in keeping with that reported in prior literature. The most common indication for the study was for obscure gastrointestinal bleed.
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Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB461