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Tu1620 Role of Small Bowel Capsule Endoscopy in Patients With Hereditary Intestinal Polyposis: A Single Center Experience
Abstracts
lesions were resected by EMR only (single session or peace meal polypectomy). 22.4% required additional argon-plasma-coagulation. Due to size (⬍ 4 mm), 5.1% were treated by forceps biopsy and additional APC-therapy. Local recurrence developed in 42.3% and was retreated endoscopically. Only one major complication (single perforation) was recorded. Minor complications (14.2%) consisted in either immediate bleeding after resection or bleeding up to 48 h after endoscopic therapy. All complications could be managed endoscopically.Endoscopic mucosal resection, if necessary combined with argonplasma-coagulation, represents an efficient and acceptably safe technique for treating duodenal adenomata. However, in comparison with colonic polypectomy, local recurrence and complications are more common. Follow-up endoscopy is recommended in short intervals such as 3 months. As relevant bleeding can occur up to 48 hours after resection, patients are in need of close monitoring. EMR should therefore not be performed in an outpatient setting.
Tu1620 Role of Small Bowel Capsule Endoscopy in Patients With Hereditary Intestinal Polyposis: A Single Center Experience Dario Moneghini1, Guido Missale1, Riccardo Nascimbeni2, Luigi Minelli1, Gianpaolo Cengia1, Renzo Cestari1 1 Surgery, Digestive Endoscopy Unit Spedali Civili of Brescia, Brescia, Italy; 2Surgery, Unit of General Surgery, Brescia, Italy Small bowel capsule endoscopy (CE) is a diagnostic tool proposed for screening and surveillance of patients with hereditary intestinal polyposis (HIP). Despite CE showed higher accuracy in polyps detection than coventional radiological techniques, its routinary use is debated and its impact on patients management has still to be clarified. We report our CE experience in 15 patients with HIP studied over a 2-years period by using the Given M2A video capsule system (Pillcam; Given Imaging Ltd, Yoqneam, Israel). Eight patients had Familial Adenomatous Polyposis (FAP), six had Peutz-Jeghers Syndrome (PJS) and one had Juvenile Polyposis (JP). In all the cases indication for CE was surveillance (no patient had newly diagnosed polyposis or small bowel related symptoms); all of them had upper and lower endoscopy before CE. The day before the exam bowel preparation with 2L of polyethylene glycol solution was administered. Capsule ingestion was performed in the morning after a overnight fast. All patients gave their written informed consent. Location (duodenum, jejunum, ileum), number (1-5; 6-20; ⬎20) and approximate size (1-5 mm; 6-10 mm; ⬎10 mm) of polyps were assessed. For FAP patients Spiegelman’s score (Ss) was calculated. Seven patients were males. The mean age was 36,4 years (range 1759). Capsule reached ileo-cecal valve (or ileo-rectal anastomosis or ileo-anal pouch) without complications in all the cases. No technical problems related to imagine transmission were recorded. Number and size of polyps found are reported in the table.Abnormal findings were observed in 93.3% of patients and 46,7% of them had significant changes in clinical management after CE: FAP patients n.2 and 3, JP patient and PJS patient n.9, 12, and 14 had endoscopic polipectomy; biopsies on submucosal masses of PJS case n.11 showed multifocal carcinoid and patient was sent to surgery. Our data confirm that CE is a safe and useful device for HIP surveillance, even in patients without symptoms and in FAP cases with low Ss. CE leads to relevant clinical management changes in almost half of patients, especially in PJS. POLYPOSIS (Ss)
DUODENUM
1 2 3 4 5 6 7 8 9 10 11
FAP (3) FAP (0) FAP (0) FAP (0) FAP (0) FAP (0) FAP (0) FAP (3) PJS PJS PJS
Normal Normal 1-5/⬎10mm Normal Normal Normal Normal 1-5/⬍5mm 1-5/⬍5mm 1-5/⬍5mm Normal
12 13 14
PJS PJS PJS
1/⬎10mm Normal 1/⬎10mm
15
JP
1-5/⬍5mm
PATIENT
www.giejournal.org
JEJUNUM
ILEUM
6-20/⬍5mm Normal 6-20/1-10mm 1-5/⬍5mm Normal Normal Normal Normal 1-5/1-5mm 1-5/1-5mm Normal 1-5/1-5mm 1-5/1-5mm ⬎20/⬍5mm Normal Normal 6-20/1-5mm 1-5/⬎10mm 6-20/1-10mm ⬎20/⬍5mm ⬎20/⬍5mm Normal 6-20/1-5mm 3 submucosal masses 6-20/1-10mm ⬎20/⬍5mm 1-5/⬍5mm Normal 6-20/1-5mm 1-5/6-10mm 6-20/1-5mm 1-5/⬎10mm 1-5/⬎10mm ⬎20/⬍5mm ⬎20/⬍5mm 1-5/⬎10mm
Tu1621 Double Balloon Enteroscopy Assisted Percutaneous Jejunostomy Placement Albert Shalomov, Syed A. Hussain, Sang H. Kim, Frank M. Palumbo, Moshe Rubin Gastroenterology, New York Hospital Queens, Flushing, NY Introduction: Jejunostomy feeding tube placement is an accepted method for obtaining enteral access. Current methods include radiologically placed percutaneuos gastrojejunostomy, endoscopically placed jejunostomy using push enteroscopy, and surgically placed jejunostomy. Recent reports suggest a high success rate of Double Balloon (DBE) assisted jejunostomy tube placement.Aim: To prospectively evaluate the success rate and patient outcomes of double balloon enteroscopy assisted placement of percutaneous jejunostomy(PEJ) tubes. Methods: Eight DBE assisted PEJ tube placements were attempted at New York Hospital Queens between August 2009 and June 2010. Indications for the procedure included leaking PEG site (2), gastroparesis (2), gastric outlet obstruction (1), recurrent aspiration with PEG tube (1), unsuccessful PEG placement (1), and cellulitis at PEG site (1). A suitable location was determined by transillumination and percutaneous invagination. A 22-gauge needle was passed initially to confirm the location. The 22-gauge needle was then snared within the small bowel loop, to prevent further movement of the bowel. Subsequently, a 19-gauge filter needle (Boston Scientific - EndoVine kit) was percutaneously inserted into the same location. A feeding tube was then placed using the standard wire guided pull technique. Results: Six male and two female patients were included in our case series. The median age was 59 (range 48-93). 7/8 attempted procedures were technically successful. In one procedure, a suitable location could not be identified due to obesity. The median time of procedure was 56.5 (20-75) minutes. All jejunostomy tubes were placed within 100 cm of the ligament of Treitz. One patient developed an enterocolonic fistula and died on day 26. There were no other complications. Conclusion: DBE successfully facilitates PEJ placement with a relatively low morbidity and mortality.
Tu1622 Intestinal Permeability to Sugars May Help in Selecting Patients Who Need Wireless Capsule Endoscopy (WCE) Barollo Michela, Renata D’Incà, Caccaro Roberta, Francesca Lamboglia, Ugoni Antonella, Piovanello Maria, Marco Scarpa, Andrea Buda, Giacomo C. Sturniolo department of gastroenterological and surgical sciences, section of gastroenterology, University of Padova, Padova, Italy Introduction: :Wireless capsule endoscopy has provided a simple and precise study of the small bowel and it has been recognised as the ultimate procedure in the search of sources of obscure bleeding. It has proved to be useful in diagnosis Crohn’ disease, in dectection of small bowel tumors and in the screening of patients with suspected small bowel disease, however its diagnostic effectiveness for symptoms such as abdominal pain and chronic diarrhea is still controversial. Intestinal permeability measured with sugars lactulose/mannitol (the L/M test) reflects the integrity of mucosal barrier and an alteration has been reported in various intestinal conditions such as, celiac disease, infectious gastroenteritis, food intolerance and allergy and in the follow up of celiac and Crohn’s disease. This study was undertaken to evaluate the role of L/M test in predicting the diagnostic findings of capsule endoscopy. Methods: 192 consecutive patients(pts) mean age 38 (11-81), 118 female and 74 male, underwent capsule endoscopy. Referral were abdominal pain 53 pts, chronic diarrhea 67 pts, abdominal pain and diarrhea 68 pts, suspected malasorption 4 pts. LM test was administered to all patients before capsule endoscopy. Results: Adequate visualization of the small bowel was reached in 94,8% of patients. All patients had previous upper and lower endoscopy with no final diagnosis. Diagnostic yields of WCE were 64% for chronic diarrhea, 60% for abdominal pain and diarrhea and 58% for abdominal pain. 53 pts had a normal L/M test (27,6%), 139 had an alterated permeability test (72,4%). L/M test had a 70% diagnostic yield combined with WCE. Patients with abdominal pain associated with diarrhea and an altered L/M test (68%altered vs 32%normal p⬍0.05) or with chronic diarrhea and altered L/M test(73,5%altered vs 39% normal p⬍0.05) had significantly more probability to have lesion at WCE. Abdominal pain results at quite high probability of lesions at capsule but irrespective to L/M test results.(57,5% altered vs 60% normal). The findings at WCE were erosions/ulcer, active Crohn’s disease, ileal nodular hyperplasia, angiomata. 26/30 pts with Ileal nodular hyperplasia at WCE had a concomitant abnormal L/M test. Conclusion: Capsule diagnostic yield can be increased with an adequate patients selection, measuring intestinal permeability may help in this pourpose. In patients with abdominal pain an altered L/M was not associated with WCE findings.
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB465
lesions were resected by EMR only (single session or peace meal polypectomy). 22.4% required additional argon-plasma-coagulation. Due to size (⬍ 4 mm), 5.1% were treated by forceps biopsy and additional APC-therapy. Local recurrence developed in 42.3% and was retreated endoscopically. Only one major complication (single perforation) was recorded. Minor complications (14.2%) consisted in either immediate bleeding after resection or bleeding up to 48 h after endoscopic therapy. All complications could be managed endoscopically.Endoscopic mucosal resection, if necessary combined with argonplasma-coagulation, represents an efficient and acceptably safe technique for treating duodenal adenomata. However, in comparison with colonic polypectomy, local recurrence and complications are more common. Follow-up endoscopy is recommended in short intervals such as 3 months. As relevant bleeding can occur up to 48 hours after resection, patients are in need of close monitoring. EMR should therefore not be performed in an outpatient setting.
Tu1620 Role of Small Bowel Capsule Endoscopy in Patients With Hereditary Intestinal Polyposis: A Single Center Experience Dario Moneghini1, Guido Missale1, Riccardo Nascimbeni2, Luigi Minelli1, Gianpaolo Cengia1, Renzo Cestari1 1 Surgery, Digestive Endoscopy Unit Spedali Civili of Brescia, Brescia, Italy; 2Surgery, Unit of General Surgery, Brescia, Italy Small bowel capsule endoscopy (CE) is a diagnostic tool proposed for screening and surveillance of patients with hereditary intestinal polyposis (HIP). Despite CE showed higher accuracy in polyps detection than coventional radiological techniques, its routinary use is debated and its impact on patients management has still to be clarified. We report our CE experience in 15 patients with HIP studied over a 2-years period by using the Given M2A video capsule system (Pillcam; Given Imaging Ltd, Yoqneam, Israel). Eight patients had Familial Adenomatous Polyposis (FAP), six had Peutz-Jeghers Syndrome (PJS) and one had Juvenile Polyposis (JP). In all the cases indication for CE was surveillance (no patient had newly diagnosed polyposis or small bowel related symptoms); all of them had upper and lower endoscopy before CE. The day before the exam bowel preparation with 2L of polyethylene glycol solution was administered. Capsule ingestion was performed in the morning after a overnight fast. All patients gave their written informed consent. Location (duodenum, jejunum, ileum), number (1-5; 6-20; ⬎20) and approximate size (1-5 mm; 6-10 mm; ⬎10 mm) of polyps were assessed. For FAP patients Spiegelman’s score (Ss) was calculated. Seven patients were males. The mean age was 36,4 years (range 1759). Capsule reached ileo-cecal valve (or ileo-rectal anastomosis or ileo-anal pouch) without complications in all the cases. No technical problems related to imagine transmission were recorded. Number and size of polyps found are reported in the table.Abnormal findings were observed in 93.3% of patients and 46,7% of them had significant changes in clinical management after CE: FAP patients n.2 and 3, JP patient and PJS patient n.9, 12, and 14 had endoscopic polipectomy; biopsies on submucosal masses of PJS case n.11 showed multifocal carcinoid and patient was sent to surgery. Our data confirm that CE is a safe and useful device for HIP surveillance, even in patients without symptoms and in FAP cases with low Ss. CE leads to relevant clinical management changes in almost half of patients, especially in PJS. POLYPOSIS (Ss)
DUODENUM
1 2 3 4 5 6 7 8 9 10 11
FAP (3) FAP (0) FAP (0) FAP (0) FAP (0) FAP (0) FAP (0) FAP (3) PJS PJS PJS
Normal Normal 1-5/⬎10mm Normal Normal Normal Normal 1-5/⬍5mm 1-5/⬍5mm 1-5/⬍5mm Normal
12 13 14
PJS PJS PJS
1/⬎10mm Normal 1/⬎10mm
15
JP
1-5/⬍5mm
PATIENT
www.giejournal.org
JEJUNUM
ILEUM
6-20/⬍5mm Normal 6-20/1-10mm 1-5/⬍5mm Normal Normal Normal Normal 1-5/1-5mm 1-5/1-5mm Normal 1-5/1-5mm 1-5/1-5mm ⬎20/⬍5mm Normal Normal 6-20/1-5mm 1-5/⬎10mm 6-20/1-10mm ⬎20/⬍5mm ⬎20/⬍5mm Normal 6-20/1-5mm 3 submucosal masses 6-20/1-10mm ⬎20/⬍5mm 1-5/⬍5mm Normal 6-20/1-5mm 1-5/6-10mm 6-20/1-5mm 1-5/⬎10mm 1-5/⬎10mm ⬎20/⬍5mm ⬎20/⬍5mm 1-5/⬎10mm
Tu1621 Double Balloon Enteroscopy Assisted Percutaneous Jejunostomy Placement Albert Shalomov, Syed A. Hussain, Sang H. Kim, Frank M. Palumbo, Moshe Rubin Gastroenterology, New York Hospital Queens, Flushing, NY Introduction: Jejunostomy feeding tube placement is an accepted method for obtaining enteral access. Current methods include radiologically placed percutaneuos gastrojejunostomy, endoscopically placed jejunostomy using push enteroscopy, and surgically placed jejunostomy. Recent reports suggest a high success rate of Double Balloon (DBE) assisted jejunostomy tube placement.Aim: To prospectively evaluate the success rate and patient outcomes of double balloon enteroscopy assisted placement of percutaneous jejunostomy(PEJ) tubes. Methods: Eight DBE assisted PEJ tube placements were attempted at New York Hospital Queens between August 2009 and June 2010. Indications for the procedure included leaking PEG site (2), gastroparesis (2), gastric outlet obstruction (1), recurrent aspiration with PEG tube (1), unsuccessful PEG placement (1), and cellulitis at PEG site (1). A suitable location was determined by transillumination and percutaneous invagination. A 22-gauge needle was passed initially to confirm the location. The 22-gauge needle was then snared within the small bowel loop, to prevent further movement of the bowel. Subsequently, a 19-gauge filter needle (Boston Scientific - EndoVine kit) was percutaneously inserted into the same location. A feeding tube was then placed using the standard wire guided pull technique. Results: Six male and two female patients were included in our case series. The median age was 59 (range 48-93). 7/8 attempted procedures were technically successful. In one procedure, a suitable location could not be identified due to obesity. The median time of procedure was 56.5 (20-75) minutes. All jejunostomy tubes were placed within 100 cm of the ligament of Treitz. One patient developed an enterocolonic fistula and died on day 26. There were no other complications. Conclusion: DBE successfully facilitates PEJ placement with a relatively low morbidity and mortality.
Tu1622 Intestinal Permeability to Sugars May Help in Selecting Patients Who Need Wireless Capsule Endoscopy (WCE) Barollo Michela, Renata D’Incà, Caccaro Roberta, Francesca Lamboglia, Ugoni Antonella, Piovanello Maria, Marco Scarpa, Andrea Buda, Giacomo C. Sturniolo department of gastroenterological and surgical sciences, section of gastroenterology, University of Padova, Padova, Italy Introduction: :Wireless capsule endoscopy has provided a simple and precise study of the small bowel and it has been recognised as the ultimate procedure in the search of sources of obscure bleeding. It has proved to be useful in diagnosis Crohn’ disease, in dectection of small bowel tumors and in the screening of patients with suspected small bowel disease, however its diagnostic effectiveness for symptoms such as abdominal pain and chronic diarrhea is still controversial. Intestinal permeability measured with sugars lactulose/mannitol (the L/M test) reflects the integrity of mucosal barrier and an alteration has been reported in various intestinal conditions such as, celiac disease, infectious gastroenteritis, food intolerance and allergy and in the follow up of celiac and Crohn’s disease. This study was undertaken to evaluate the role of L/M test in predicting the diagnostic findings of capsule endoscopy. Methods: 192 consecutive patients(pts) mean age 38 (11-81), 118 female and 74 male, underwent capsule endoscopy. Referral were abdominal pain 53 pts, chronic diarrhea 67 pts, abdominal pain and diarrhea 68 pts, suspected malasorption 4 pts. LM test was administered to all patients before capsule endoscopy. Results: Adequate visualization of the small bowel was reached in 94,8% of patients. All patients had previous upper and lower endoscopy with no final diagnosis. Diagnostic yields of WCE were 64% for chronic diarrhea, 60% for abdominal pain and diarrhea and 58% for abdominal pain. 53 pts had a normal L/M test (27,6%), 139 had an alterated permeability test (72,4%). L/M test had a 70% diagnostic yield combined with WCE. Patients with abdominal pain associated with diarrhea and an altered L/M test (68%altered vs 32%normal p⬍0.05) or with chronic diarrhea and altered L/M test(73,5%altered vs 39% normal p⬍0.05) had significantly more probability to have lesion at WCE. Abdominal pain results at quite high probability of lesions at capsule but irrespective to L/M test results.(57,5% altered vs 60% normal). The findings at WCE were erosions/ulcer, active Crohn’s disease, ileal nodular hyperplasia, angiomata. 26/30 pts with Ileal nodular hyperplasia at WCE had a concomitant abnormal L/M test. Conclusion: Capsule diagnostic yield can be increased with an adequate patients selection, measuring intestinal permeability may help in this pourpose. In patients with abdominal pain an altered L/M was not associated with WCE findings.
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB465