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Wireless Capsule Enteroscopy: A Comparison with Enterography, Push Enteroscopy and Ileo-colonoscopy in the Diagnosis of Small Bowel Crohn's Disease
*M1807 Capsule Endoscopy: Improving the Transit Time and the Image View Zvi Fireman, Dan Paz Background: The capsule endoscopy (CE) record video images during natural propulsion through the small bowel. Practical experience has shown that visualization of the entire small bowel mucosa may sometimes be hindered by the presence of residual material. Shorting the transit times of the CE through the stomach and small bowel might help the time needed to read the CE as well the short life of the CE battery(761 hours) and may be insufficient to image the entire small bowel. Aims: To evaluate the effect of various methods of small bowel preparation on the quality of visualization of the entire small bowel mucosa. Material and Methods:. 95 patients underwent CE by easily swallowing the capsule. They were divided into three study groups according to the preparation used. Group A (n = 26) by polyethylene glycol liter (PEG) or with sodium phosphate (SP) 12 hours prior to the CE study. Group B (n = 29) by Erythromycin one hour prior to the CE study and Group C (n = 40) with no preparation. One (1.05%) case had no natural excretion. Visualization ranged from good through satisfactory and poor. Results: The mean emptying gastric time was 41.7651.5 minutes and the transit time of the small bowel was 225680.6 minutes. In elderly people the emptying gastric time was significantly longer (163.7 min.), in patient prepared by PEG or SP (P 0.05) compare to the other preparation. The gender and the presence pathology had no effect on the study group The grade of the cleaning of the all study group was 3.2761.1, the worst quality of image were significantly (P= 0.05) in the Erythromycin group compare to the other sub-group. The age, gender and the presence pathology had no effect on the quality of the cleaning of the small bowel study group. One (1.05%) case had no natural excretion. Visualization ranged from good through satisfactory and poor. Conclusions: Erythromycin have shorter time in the stomach but have a negative effect on the quality of the image in the small bowel. The preparation with in PEG or SP have a negative effect on the transit time of the small. The quality of the visualization in Erythromycin group was the worst.
*M1808 The Capsule Is Not Better and Is Less Cost-Effective Than Conventional Means in Diagnosing Small Bowel Pathology (i.e.: Crohn), but Superior to Enteroclysis in Mapping its Extent George Katsoras, George Grammatopoulos, Charalambos Pavlopoulos, Greg Tsiotos, Konstantinos Delis, Anastasios Grammatopoulos Background: The capsule has been suggested as the optimal method of establishing the diagnosis in patients with obscure chronic diarrhea (>30 days, nondiagnosed otherwise), especially when related to Crohn disease (CD). Aim: To compare the efficacy of the capsule to appropriately utilized and more cost-effective conventional means in establishing the diagnosis in patients with obscure chronic diarrhea (where gastric and colonic pathology has been excluded) and to enteroclysis in identifying the extent of small bowel (SB) involvement. Methods: All patients with obscure chronic diarrhea referred to our tertiary referral center between 6/02 and 10/03, were subjected to 1. upper and lower GI endoscopy (including the terminal ileum-TI), endoscopic biopsies (of suspicious lesions and random gastric, duodenal and TI in all), 2. SB capsule endoscopy, and 3. enteroclysis (if they consented). Results: Fifty two patients (M/F: 25/27, Mean age 37yrs, range: 16-67 yrs) were studied. Endoscopy and biopsies provided histologic diagnosis in 51 (98%): CD (42), infectious enteritis (3), celiac sprue (2), eosinophilic enteritis (1), nonspecific enteritis (1), allergic enteritis (1), and immunodeficiency syndrome (1). It was negative in one patient where CD was diagnosed on the capsule findings alone (2%). Only 39 patients (75%) consented to enteroclysis, which demonstrated one SB segment involved with CD in 12 (31%). The capsule demonstrated more than one SB segments involved with disease in all of these 39 (p=0.03). Overall, the capsule demonstrated more than one SB segments involved with disease in 50/52 (96%). Summary: This study demonstrates that the capsule offers very limited advantage in establishing the cause of obscure chronic diarrhea, since endoscopy and appropriate biopsies are diagnostic in the overwhelming majority of patients. However, the capsule provides significant advantage in identifying the exact extent of the disease over enteroclysis, which is also less well accepted by patients. Conclusion: The capsule is rarely necessary to establish the diagnosis of atypical SB pathology, especially CD, when cheaper conventional means are appropriately utilized. However, it is better tolerated and provides the best available method of mapping the extent of SB involvement by the disease.
*M1809 Wireless Capsule Enteroscopy: A Comparison with Enterography, Push Enteroscopy and Ileo-colonoscopy in the Diagnosis of Small Bowel Crohn's Disease Ervin Toth, Frans-Thomas Fork, Per Almqvist, Cecilia Benoni, Olle Ekberg, Olof Grip, Tornbjorn Gustafson, Stefan Lindgren, Bodil Ohlsson, Rolf Olsson, Klas Sjoberg, Hans Verbaan VOLUME 59, NO. 5, 2004
Background: Conventional radiological and endoscopic imaging methods of the small bowel (SB) have several limitations, which often delays diagnosis and adequate treatment of small bowel Crohn’s disease (SBCD). The recent introduction of Given M2A capsule enteroscopy (CE) may change this scenario, by enabling direct visualization of the entire SB mucosa. Objective: To evaluate the diagnostic value of CE, versus barium enterography (BE), push enteroscopy (PE) and ileo-colonoscopy (IC) in SBCD. Patients and methods: 53 consecutive patients (40 women and 13 men, mean age 36 years, range 14-62), with clinically suspected active CD were included in a prospective, controlled study. Eligible patients had either suspected (61%), based on predefined clinical and biochemical markers, or previously diagnosed CD (39%). Five patients with SB stricture detected on BE and one patient with ischemic enteropathy were excluded from the study. 47 patients completed all 4 examinations, i.e. standard BE (89% enteroclysis, 11% SB follow through), IC, PE and CE were evaluated. All examinations were performed within 3 months by experienced investigators. Results: Crohn’s lesions (multiple erosions, ulcerations and/or strictures) in the SB were visualized by one or more methods in 25 (53%) of the 47 patients. All cases with SBCD detected on BE, PE and IC were also identified using CE except 3 (12%) cases where the capsule did not pass through the entire SB during the examination. Notably, CE identified 4 additional patients with CD and detected more extended SBCD in 6 (24%) patients compared to the other methods. Intubation of ileum was unsuccessful in 3 (12%) cases examined by IC. All examinations were performed without complications. The capsule was easily swallowed by all patients and was expelled without side effects. CE was preferred to BE by 95% of patients. Sensitivity and specificity of the studied methods for detecting SBCD are showed in the table. Conclusions: CE is a safe, well-tolerated and more sensitive imaging modality for visualizing Crohn’s lesions in the entire SB compared with BE, PE and IC. Our data suggest that capsule endoscopy may be considered as a first line imaging examination in patients with suspected, non-stricturing small bowel Crohn’s disease.
*M1810 A Prospective Study of Cox-2 Inhibitors vs NSAIDS Induced Small Bowel Lesions in Asymptomatic Patients Using Video Capsule Endoscopy Jose Luis Vazquez-Iglesias, Benito Gonzalez-Conde, Emilio EstevezPrieto, David Martinez-Ares, Fausto Galdo, Genaro Grana, Antonio Atanes INTRODUCTION: Patients who regularly take NSAIDs have an increased risk of small intestinal mucosal ulceration and bleeding. These ulcers are less common than ulcers of the stomach or duodenum, but can lead to life-threatening complications. Esophageal, gastric and duodenal mucosal injuries have been extensively evaluated using endoscopy, but evaluation of areas beyond the reach of routine endoscopy has been limited to autopsy studies and clinical cases with adverse outcome. AIMS AND METHODS: The objective of this study is to assess the utility of the Given Video Capsule Endocope (VCE) in determining the difference between small bowel injury in NSAIDs (Piroxicam) versus Cox-2 inhibitors (Celecoxib) gastrointestinal asymptomatic users. Exclusion criteria were pregnancy, mental or physical condition wich precludes compliance with study or device instructions or ingestion of the capsule, suspected or known strictures or obstruction of small intestine, prior abdominal surgery and patients with cardiac pacemakers or other implanted electromedical devices. All patients fasted overnight and underwent VCE. Two investigators reviewed each video beginning after the pylorus. RESULTS: 20 patients (14 women, mean age 55,2 years) were enrolled. 9 patients took Piroxicam 20-40 mg/day(group A) and 11 patients took Celecoxib 100-200 mg/day (group B). Median hemoglobin was 13,2 g/dl. VCE detect erosions and small ulcers in small intestine in 5 patients of group A versus 8 patients of group B (p=0,64). The number of total lesions are summarized in table I. Jejunum were the site where more lesions were found. Incidental lesions (lymphangiectasia, submucosal tumours and angiodysplasia) were found in 3 patients. There were no complications related with the procedure. CONCLUSIONS: Small bowel injury in gastrointestinal asyntomatic patients who take regularly Piroxicam or Celecoxibin is much more common than suspected. In this small group of patients, Celecoxib is associated with more lesions in the small bowel compared with Piroxicam, but without statistical significance.
GASTROINTESTINAL ENDOSCOPY
P173
*M1808 The Capsule Is Not Better and Is Less Cost-Effective Than Conventional Means in Diagnosing Small Bowel Pathology (i.e.: Crohn), but Superior to Enteroclysis in Mapping its Extent George Katsoras, George Grammatopoulos, Charalambos Pavlopoulos, Greg Tsiotos, Konstantinos Delis, Anastasios Grammatopoulos Background: The capsule has been suggested as the optimal method of establishing the diagnosis in patients with obscure chronic diarrhea (>30 days, nondiagnosed otherwise), especially when related to Crohn disease (CD). Aim: To compare the efficacy of the capsule to appropriately utilized and more cost-effective conventional means in establishing the diagnosis in patients with obscure chronic diarrhea (where gastric and colonic pathology has been excluded) and to enteroclysis in identifying the extent of small bowel (SB) involvement. Methods: All patients with obscure chronic diarrhea referred to our tertiary referral center between 6/02 and 10/03, were subjected to 1. upper and lower GI endoscopy (including the terminal ileum-TI), endoscopic biopsies (of suspicious lesions and random gastric, duodenal and TI in all), 2. SB capsule endoscopy, and 3. enteroclysis (if they consented). Results: Fifty two patients (M/F: 25/27, Mean age 37yrs, range: 16-67 yrs) were studied. Endoscopy and biopsies provided histologic diagnosis in 51 (98%): CD (42), infectious enteritis (3), celiac sprue (2), eosinophilic enteritis (1), nonspecific enteritis (1), allergic enteritis (1), and immunodeficiency syndrome (1). It was negative in one patient where CD was diagnosed on the capsule findings alone (2%). Only 39 patients (75%) consented to enteroclysis, which demonstrated one SB segment involved with CD in 12 (31%). The capsule demonstrated more than one SB segments involved with disease in all of these 39 (p=0.03). Overall, the capsule demonstrated more than one SB segments involved with disease in 50/52 (96%). Summary: This study demonstrates that the capsule offers very limited advantage in establishing the cause of obscure chronic diarrhea, since endoscopy and appropriate biopsies are diagnostic in the overwhelming majority of patients. However, the capsule provides significant advantage in identifying the exact extent of the disease over enteroclysis, which is also less well accepted by patients. Conclusion: The capsule is rarely necessary to establish the diagnosis of atypical SB pathology, especially CD, when cheaper conventional means are appropriately utilized. However, it is better tolerated and provides the best available method of mapping the extent of SB involvement by the disease.
*M1809 Wireless Capsule Enteroscopy: A Comparison with Enterography, Push Enteroscopy and Ileo-colonoscopy in the Diagnosis of Small Bowel Crohn's Disease Ervin Toth, Frans-Thomas Fork, Per Almqvist, Cecilia Benoni, Olle Ekberg, Olof Grip, Tornbjorn Gustafson, Stefan Lindgren, Bodil Ohlsson, Rolf Olsson, Klas Sjoberg, Hans Verbaan VOLUME 59, NO. 5, 2004
Background: Conventional radiological and endoscopic imaging methods of the small bowel (SB) have several limitations, which often delays diagnosis and adequate treatment of small bowel Crohn’s disease (SBCD). The recent introduction of Given M2A capsule enteroscopy (CE) may change this scenario, by enabling direct visualization of the entire SB mucosa. Objective: To evaluate the diagnostic value of CE, versus barium enterography (BE), push enteroscopy (PE) and ileo-colonoscopy (IC) in SBCD. Patients and methods: 53 consecutive patients (40 women and 13 men, mean age 36 years, range 14-62), with clinically suspected active CD were included in a prospective, controlled study. Eligible patients had either suspected (61%), based on predefined clinical and biochemical markers, or previously diagnosed CD (39%). Five patients with SB stricture detected on BE and one patient with ischemic enteropathy were excluded from the study. 47 patients completed all 4 examinations, i.e. standard BE (89% enteroclysis, 11% SB follow through), IC, PE and CE were evaluated. All examinations were performed within 3 months by experienced investigators. Results: Crohn’s lesions (multiple erosions, ulcerations and/or strictures) in the SB were visualized by one or more methods in 25 (53%) of the 47 patients. All cases with SBCD detected on BE, PE and IC were also identified using CE except 3 (12%) cases where the capsule did not pass through the entire SB during the examination. Notably, CE identified 4 additional patients with CD and detected more extended SBCD in 6 (24%) patients compared to the other methods. Intubation of ileum was unsuccessful in 3 (12%) cases examined by IC. All examinations were performed without complications. The capsule was easily swallowed by all patients and was expelled without side effects. CE was preferred to BE by 95% of patients. Sensitivity and specificity of the studied methods for detecting SBCD are showed in the table. Conclusions: CE is a safe, well-tolerated and more sensitive imaging modality for visualizing Crohn’s lesions in the entire SB compared with BE, PE and IC. Our data suggest that capsule endoscopy may be considered as a first line imaging examination in patients with suspected, non-stricturing small bowel Crohn’s disease.
*M1810 A Prospective Study of Cox-2 Inhibitors vs NSAIDS Induced Small Bowel Lesions in Asymptomatic Patients Using Video Capsule Endoscopy Jose Luis Vazquez-Iglesias, Benito Gonzalez-Conde, Emilio EstevezPrieto, David Martinez-Ares, Fausto Galdo, Genaro Grana, Antonio Atanes INTRODUCTION: Patients who regularly take NSAIDs have an increased risk of small intestinal mucosal ulceration and bleeding. These ulcers are less common than ulcers of the stomach or duodenum, but can lead to life-threatening complications. Esophageal, gastric and duodenal mucosal injuries have been extensively evaluated using endoscopy, but evaluation of areas beyond the reach of routine endoscopy has been limited to autopsy studies and clinical cases with adverse outcome. AIMS AND METHODS: The objective of this study is to assess the utility of the Given Video Capsule Endocope (VCE) in determining the difference between small bowel injury in NSAIDs (Piroxicam) versus Cox-2 inhibitors (Celecoxib) gastrointestinal asymptomatic users. Exclusion criteria were pregnancy, mental or physical condition wich precludes compliance with study or device instructions or ingestion of the capsule, suspected or known strictures or obstruction of small intestine, prior abdominal surgery and patients with cardiac pacemakers or other implanted electromedical devices. All patients fasted overnight and underwent VCE. Two investigators reviewed each video beginning after the pylorus. RESULTS: 20 patients (14 women, mean age 55,2 years) were enrolled. 9 patients took Piroxicam 20-40 mg/day(group A) and 11 patients took Celecoxib 100-200 mg/day (group B). Median hemoglobin was 13,2 g/dl. VCE detect erosions and small ulcers in small intestine in 5 patients of group A versus 8 patients of group B (p=0,64). The number of total lesions are summarized in table I. Jejunum were the site where more lesions were found. Incidental lesions (lymphangiectasia, submucosal tumours and angiodysplasia) were found in 3 patients. There were no complications related with the procedure. CONCLUSIONS: Small bowel injury in gastrointestinal asyntomatic patients who take regularly Piroxicam or Celecoxibin is much more common than suspected. In this small group of patients, Celecoxib is associated with more lesions in the small bowel compared with Piroxicam, but without statistical significance.
GASTROINTESTINAL ENDOSCOPY
P173