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Utility of Wireless Capsule Enteroscopy (WCE) in Evaluating Crohn's Disease Patients with Abdominal Symptoms
Abstracts
M1369 Prospective Trial Comparing Push-Enteroscopy and Push-and-Pull Enteroscopy Using Double-Balloon Technique in Patients with Small Bowel Diseases Andrea May, Lars Nachbar, Marion Schneider, Christian Ell
M1371 Utility of Wireless Capsule Enteroscopy (WCE) in Evaluating Crohn’s Disease Patients with Abdominal Symptoms Shahab Mehdizadeh, Gary C. Chen, Pedram J. Enayati, Omid Shaye, Simon K. Lo, Konstantinos A. Papadakis
Background: Push enteroscopy (PE) is currently the ‘‘gold standard’’ of conventional small bowel enteroscopy. However, penetration depths of PE is limited. The new method of push-and-pull enteroscopy using a double-balloon technique (PPE) makes total enteroscopy possible.This prospective trial compared both methods with the regard to investigation time, insertion depths, x-ray exposure, amount of sedoanalgetic medication, diagnostic yield as well as complications. Methods: Between November 2003 and November 2004 fifty patients (32 men, 18 women with a mean age of 57 G 18 years) with suspected or known disease of the small bowel were enrolled in this prospective study. All patients underwent first push enteroscopy (Fuji EN 410 WM, Fujinon Inc. Japan) and then PPE (Fuji EN 450P5/20, Fujinon Inc. Japan). The majority of patients (38/50, 76%) suffered from chronic or acute intestinal bleeding. Results: All enteroscopies were done without complications. The amount of sedoanalgetic medication was not statistically significant using midazolam, meperidine and valium, using propofol there was a siginificant higher dosage given during PPE (p Z 0.003). There is a statistically significant difference between both methods regarding investigation time (PE 21 G 12 min vs. PPE 70 G 30 min, p % 0,001); x-ray exposure (median PE 0.65 min. vs. PPE 1.9 min., p % 0.001; PE 68 dGy/cm2 vs. PPE 160 dGy/cm2, p Z 0.007) as well as insertion depths (median PE 80 cm post pyloric vs. PPE 210 cm post pyloric, p % 0,001). The diagnostic yield of PPE is significantly higher than with PE (78% vs. 42%, p % 0.001). Conclusions: The prospective comparison proves that PPE is significant superior to PE with respect to insertion depths and diagnostic yield and should become the method of choice in patients where a deep as possible enteroscopy is required.
WCE is a new diagnostic modality for patients with suspected or known Crohn’s disease (CD). Aim: To determine the frequency of small bowel (SB) disease and the distribution of SB lesions detected by WCE among symptomatic patients with known CD. Methods: Data of all established CD patients who underwent WCE between October 2001 and February of 2004 for symptoms suggestive of active disease were retrospectively reviewed. Symptoms included abdominal pain, gastrointestinal bleeding, diarrhea, and weight loss. All images were reviewed by a single experienced endoscopist and were analyzed with respect to type and location of SB lesions. The finding of multiple ulcerations (O3) on WCE was classified as active small bowel CD. The presence of %3 ulcerations was considered suggestive of active CD. Results: Ninety-seven WCE were performed on 88 symptomatic patients with documented CD. Forty-eight of 96 (50%) patients had findings diagnostic of active CD, and 10 (10%) patients had findings suggestive of active CD. Thirty-three (34%) patients had normal findings. Forty-four of 96 (46%) procedures showed lesions in more than one region of the SB. 23%, 34%, 42%, and 51% of the lesions were in the duodenum, jejunum, proximal ileum, and distal ileum, respectively. Only 5 cases showed lesions in the duodenum, jejunum, or proximal ileum without lesions in the distal ileum (Fisher’s Exact p ! 0.0001). The capsule reached the cecum in 64 of 96 (67%) procedures and showed active colonic ulcerations in 18 cases. Twenty-two patients had colonoscopy data within 90 days (mean 30 days) of WCE. While 55% had disease findings on WCE, only one patient (5%) had a single aphthous ulcer on colonoscopy. In 32 cases a small bowel follow through (SBFT) had been performed within 90 days of the WCE procedure (mean 30 days). WCE was superior to SBFT in detecting active Crohn’s lesions (p Z 0.05). Conclusion: WCE identified active SB lesions in half of CD patients experiencing abdominal symptoms. A surprisingly large number of lesions were seen in the more proximal parts of the SB, but they rarely existed in the absence of distal ileal lesions. Our limited data suggests that colonoscopy added little value to assess active disease in symptomatic patients. Therefore, WCE may be the preferred modality in evaluating CD patients presenting with symptoms. Prospective studies are needed to assess the utility of WCE as the primary tool for evaluating patients with symptomatic CD.
M1370 The Diagnostic Yield of Wireless Capsule Enteroscopy (WCE) in Patients with Ulcerative Colitis (UC) Shahab Mehdizadeh, Gary C. Chen, Pedram J. Enayati, Omid Shaye, Victoria De Leon, Andrew Ippoliti, Simon K. Lo, Konstantinos A. Papadakis The accurate diagnosis of UC versus Crohn’s disease (CD) is very important in the medical and surgical management of patients with IBD. The clinical utility of WCE in patients with moderate to severe UC is currently unknown. Aim: To determine the diagnostic yield of WCE in patients with moderate to severe UC. Methods: All patients with moderate to severe UC who underwent WCE between October 2001 and February of 2004 were retrospectively analyzed for procedure indications and findings. All images were reviewed by a single experienced endoscopist. The finding of multiple ulcerations (O3) on WCE was classified as diagnostic of small bowel CD. Results: A total of 900 WCE procedures were performed. Seventy-one patients with known moderate to severe UC underwent 73 WCE procedures. Patients were grouped as follows: Group A, sixty-one (86%) patients with moderate to severe UC with either symptoms out of proportion to colitis such as severe abdominal pain or non-bloody diarrhea or steroid refractory disease and, Group B, ten (14%) patients with previous colectomy and continued or new onset of symptoms including diarrhea and/or abdominal pain, and pouchitis refractory to antibiotic therapy. Eleven of 61 (18%) patients in Group A had findings consistent with CD and 3 of 10 (30%) patients with previous colectomy (Group B) had findings consistent with CD. In 10 of the 73 (14%) procedures the capsule did not reach the cecum, however, there was no retention of the capsule.Among 14 patients with positive findings on WCE, 9 had a small bowel follow through within 32 days of WCE, but none showed findings consistent with CD.Thirteen patients with positive findings on WCE had serologic markers available for pANCA, ASCA, and OmpC. Thirty-four patients with negative WCE findings had serologic markers available. Only 2 of these 13 patients were positive for ASCA and/or OmpC and both were also positive for pANCA. Conclusion: A large number of patients with moderate to severe UC, regardless of history of colectomy, atypical features, or negative findings on SBFT, can be reclassified as CD when further evaluated by WCE.
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M1372 Endoscopic Mucosal Dissection (ESD) for Early Gastric Cancer (GC): A Prospective Study for Extension of the Indication of Endoscopic Mucosal Resection (EMR) Tomoki Michida, Takeshi Nakamura, Takashi Ueda, Yuko Izumi, Nobuhiro Shirahata, Eriko Satomi, Kenya Iyoda, Nobukazu Yuki, Keiji Yamamoto, Michio Kato, Masahiro Ikeda Background: Minimally invasive treatment such as EMR is widely noticed as a therapy for early GC. ESD is a promising EMR method which enables us to resect lesions en bloc as we like. Recently, in Japan, a guideline of treatment for GC shows some conditions of GC which are hardly associated with nodal metastasis. The aim of this study was to assess efficacy and safety of ESD against those lesions. Patients and Methods: We designed a prospective study in which ESD was applied in patients with differentiated-type GC up to 30 mm in diameter regardless of ulceration or above 30 mm without ulceration, but definite signs of submucosal invasion. According to final diagnosis after the ESD, GCs below, considered to have hardly metastasis, were followed up and otherwise were advised to be operated on additionally; differentiated-type mucosal GC above 30 mm in diameter without ulceration, and GC up to 30 mm with ulceration and/or minute submucosal invasion. The protocol was approved by the ethics committee of Osaka National Hospital, and consent to take part in the study was obtained from patients. Complete resection was defined if the lateral and basal margins were free of tumor pathologically. Followed-up endoscopic examinations are performed 1, 3, 6 months later, and then every six months. Results: Between Nov. 2001 and Nov. 2004, 180 lesions were enrolled. The average size of GC resected was 20 mm (range: 2-70 mm). Of 180 lesions, 144 (84%) were completely resected. Twentyseven patients were recommended to have additional operation mainly because of massive submucosal invasion or lymphovascular involvement, and nodal metastasis was recognized in two of 12 patients who were actually operated on. Two of the remaining 153 patients recurred locally during follow-up period of median 19 mos (range: 3-36), and both were successfully treated by repeated ESD. No distant metastasis was noted. Perforation and bleeding were encountered in 9% and 8% of the patients respectively, which both happened more frequently in case of GC with ulceration (p ! 0.05). No emergent surgery and no immediate mortality was noted. Conclusions: These results suggest that ESD is feasible for large mucosal GC without ulceration or for GC with ulceration and/or minute submucosal invasion up to 30 mm in diameter. However, to extend the indication of EMR for GC, correct pathological diagnosis obtained by en bloc resection is essential and the long-term prognosis should be investigated.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB175
M1369 Prospective Trial Comparing Push-Enteroscopy and Push-and-Pull Enteroscopy Using Double-Balloon Technique in Patients with Small Bowel Diseases Andrea May, Lars Nachbar, Marion Schneider, Christian Ell
M1371 Utility of Wireless Capsule Enteroscopy (WCE) in Evaluating Crohn’s Disease Patients with Abdominal Symptoms Shahab Mehdizadeh, Gary C. Chen, Pedram J. Enayati, Omid Shaye, Simon K. Lo, Konstantinos A. Papadakis
Background: Push enteroscopy (PE) is currently the ‘‘gold standard’’ of conventional small bowel enteroscopy. However, penetration depths of PE is limited. The new method of push-and-pull enteroscopy using a double-balloon technique (PPE) makes total enteroscopy possible.This prospective trial compared both methods with the regard to investigation time, insertion depths, x-ray exposure, amount of sedoanalgetic medication, diagnostic yield as well as complications. Methods: Between November 2003 and November 2004 fifty patients (32 men, 18 women with a mean age of 57 G 18 years) with suspected or known disease of the small bowel were enrolled in this prospective study. All patients underwent first push enteroscopy (Fuji EN 410 WM, Fujinon Inc. Japan) and then PPE (Fuji EN 450P5/20, Fujinon Inc. Japan). The majority of patients (38/50, 76%) suffered from chronic or acute intestinal bleeding. Results: All enteroscopies were done without complications. The amount of sedoanalgetic medication was not statistically significant using midazolam, meperidine and valium, using propofol there was a siginificant higher dosage given during PPE (p Z 0.003). There is a statistically significant difference between both methods regarding investigation time (PE 21 G 12 min vs. PPE 70 G 30 min, p % 0,001); x-ray exposure (median PE 0.65 min. vs. PPE 1.9 min., p % 0.001; PE 68 dGy/cm2 vs. PPE 160 dGy/cm2, p Z 0.007) as well as insertion depths (median PE 80 cm post pyloric vs. PPE 210 cm post pyloric, p % 0,001). The diagnostic yield of PPE is significantly higher than with PE (78% vs. 42%, p % 0.001). Conclusions: The prospective comparison proves that PPE is significant superior to PE with respect to insertion depths and diagnostic yield and should become the method of choice in patients where a deep as possible enteroscopy is required.
WCE is a new diagnostic modality for patients with suspected or known Crohn’s disease (CD). Aim: To determine the frequency of small bowel (SB) disease and the distribution of SB lesions detected by WCE among symptomatic patients with known CD. Methods: Data of all established CD patients who underwent WCE between October 2001 and February of 2004 for symptoms suggestive of active disease were retrospectively reviewed. Symptoms included abdominal pain, gastrointestinal bleeding, diarrhea, and weight loss. All images were reviewed by a single experienced endoscopist and were analyzed with respect to type and location of SB lesions. The finding of multiple ulcerations (O3) on WCE was classified as active small bowel CD. The presence of %3 ulcerations was considered suggestive of active CD. Results: Ninety-seven WCE were performed on 88 symptomatic patients with documented CD. Forty-eight of 96 (50%) patients had findings diagnostic of active CD, and 10 (10%) patients had findings suggestive of active CD. Thirty-three (34%) patients had normal findings. Forty-four of 96 (46%) procedures showed lesions in more than one region of the SB. 23%, 34%, 42%, and 51% of the lesions were in the duodenum, jejunum, proximal ileum, and distal ileum, respectively. Only 5 cases showed lesions in the duodenum, jejunum, or proximal ileum without lesions in the distal ileum (Fisher’s Exact p ! 0.0001). The capsule reached the cecum in 64 of 96 (67%) procedures and showed active colonic ulcerations in 18 cases. Twenty-two patients had colonoscopy data within 90 days (mean 30 days) of WCE. While 55% had disease findings on WCE, only one patient (5%) had a single aphthous ulcer on colonoscopy. In 32 cases a small bowel follow through (SBFT) had been performed within 90 days of the WCE procedure (mean 30 days). WCE was superior to SBFT in detecting active Crohn’s lesions (p Z 0.05). Conclusion: WCE identified active SB lesions in half of CD patients experiencing abdominal symptoms. A surprisingly large number of lesions were seen in the more proximal parts of the SB, but they rarely existed in the absence of distal ileal lesions. Our limited data suggests that colonoscopy added little value to assess active disease in symptomatic patients. Therefore, WCE may be the preferred modality in evaluating CD patients presenting with symptoms. Prospective studies are needed to assess the utility of WCE as the primary tool for evaluating patients with symptomatic CD.
M1370 The Diagnostic Yield of Wireless Capsule Enteroscopy (WCE) in Patients with Ulcerative Colitis (UC) Shahab Mehdizadeh, Gary C. Chen, Pedram J. Enayati, Omid Shaye, Victoria De Leon, Andrew Ippoliti, Simon K. Lo, Konstantinos A. Papadakis The accurate diagnosis of UC versus Crohn’s disease (CD) is very important in the medical and surgical management of patients with IBD. The clinical utility of WCE in patients with moderate to severe UC is currently unknown. Aim: To determine the diagnostic yield of WCE in patients with moderate to severe UC. Methods: All patients with moderate to severe UC who underwent WCE between October 2001 and February of 2004 were retrospectively analyzed for procedure indications and findings. All images were reviewed by a single experienced endoscopist. The finding of multiple ulcerations (O3) on WCE was classified as diagnostic of small bowel CD. Results: A total of 900 WCE procedures were performed. Seventy-one patients with known moderate to severe UC underwent 73 WCE procedures. Patients were grouped as follows: Group A, sixty-one (86%) patients with moderate to severe UC with either symptoms out of proportion to colitis such as severe abdominal pain or non-bloody diarrhea or steroid refractory disease and, Group B, ten (14%) patients with previous colectomy and continued or new onset of symptoms including diarrhea and/or abdominal pain, and pouchitis refractory to antibiotic therapy. Eleven of 61 (18%) patients in Group A had findings consistent with CD and 3 of 10 (30%) patients with previous colectomy (Group B) had findings consistent with CD. In 10 of the 73 (14%) procedures the capsule did not reach the cecum, however, there was no retention of the capsule.Among 14 patients with positive findings on WCE, 9 had a small bowel follow through within 32 days of WCE, but none showed findings consistent with CD.Thirteen patients with positive findings on WCE had serologic markers available for pANCA, ASCA, and OmpC. Thirty-four patients with negative WCE findings had serologic markers available. Only 2 of these 13 patients were positive for ASCA and/or OmpC and both were also positive for pANCA. Conclusion: A large number of patients with moderate to severe UC, regardless of history of colectomy, atypical features, or negative findings on SBFT, can be reclassified as CD when further evaluated by WCE.
www.mosby.com/gie
M1372 Endoscopic Mucosal Dissection (ESD) for Early Gastric Cancer (GC): A Prospective Study for Extension of the Indication of Endoscopic Mucosal Resection (EMR) Tomoki Michida, Takeshi Nakamura, Takashi Ueda, Yuko Izumi, Nobuhiro Shirahata, Eriko Satomi, Kenya Iyoda, Nobukazu Yuki, Keiji Yamamoto, Michio Kato, Masahiro Ikeda Background: Minimally invasive treatment such as EMR is widely noticed as a therapy for early GC. ESD is a promising EMR method which enables us to resect lesions en bloc as we like. Recently, in Japan, a guideline of treatment for GC shows some conditions of GC which are hardly associated with nodal metastasis. The aim of this study was to assess efficacy and safety of ESD against those lesions. Patients and Methods: We designed a prospective study in which ESD was applied in patients with differentiated-type GC up to 30 mm in diameter regardless of ulceration or above 30 mm without ulceration, but definite signs of submucosal invasion. According to final diagnosis after the ESD, GCs below, considered to have hardly metastasis, were followed up and otherwise were advised to be operated on additionally; differentiated-type mucosal GC above 30 mm in diameter without ulceration, and GC up to 30 mm with ulceration and/or minute submucosal invasion. The protocol was approved by the ethics committee of Osaka National Hospital, and consent to take part in the study was obtained from patients. Complete resection was defined if the lateral and basal margins were free of tumor pathologically. Followed-up endoscopic examinations are performed 1, 3, 6 months later, and then every six months. Results: Between Nov. 2001 and Nov. 2004, 180 lesions were enrolled. The average size of GC resected was 20 mm (range: 2-70 mm). Of 180 lesions, 144 (84%) were completely resected. Twentyseven patients were recommended to have additional operation mainly because of massive submucosal invasion or lymphovascular involvement, and nodal metastasis was recognized in two of 12 patients who were actually operated on. Two of the remaining 153 patients recurred locally during follow-up period of median 19 mos (range: 3-36), and both were successfully treated by repeated ESD. No distant metastasis was noted. Perforation and bleeding were encountered in 9% and 8% of the patients respectively, which both happened more frequently in case of GC with ulceration (p ! 0.05). No emergent surgery and no immediate mortality was noted. Conclusions: These results suggest that ESD is feasible for large mucosal GC without ulceration or for GC with ulceration and/or minute submucosal invasion up to 30 mm in diameter. However, to extend the indication of EMR for GC, correct pathological diagnosis obtained by en bloc resection is essential and the long-term prognosis should be investigated.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB175