DDW Highlights
787
Authors
Enrique Pérez-Cuadrado Martínez, Enrique Pérez-Cuadrado Robles
Institution
Small Bowel Unit, Digestive Service, Morales Meseguer Hospital, Murcia, Spain
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1377448 Published online: 18.8.2014 Endoscopy 2014; 46: 787–790 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X
During the 2014 Digestive Disease Week in Chicago, many high-quality studies on small-bowel endoscopy were presented. The most relevant abstracts from around the world of two comple-
mentary procedures – capsule endoscopy and deep enteroscopy – which have seen rapid changes in recent years, have been selected for this review.
Capsule endoscopy
transit time (178.5, 110.5, and 122.5 minutes in the P-P, P-L, and L-P groups, respectively). In addition, lubiprostone was effective in inducing water secretion into the small bowel (1 ± 1.65, 4 ± 1.29, and 4 ± 1.64 in the P-P, P-L, and L-P groups, respectively; P < 0.01), and improved the visualization of the small bowel during VCE (3 ± 1.35, 4 ± 0.85, and 4 ± 0.56 in the P-P, P-L, and L-P groups, respectively; P < 0.01). Studies that include more patients are needed to determine whether or not the lubiprostone with or without various purgative prokinetics improves the diagnostic yield of VCE.
Corresponding author Enrique Pérez-Cuadrado Martínez, MD Hospital Morales Meseguer (U. Endoscopia) c/Marqués de los Vélez SN 30008 Murcia Spain Fax: +34-968-359777 [email protected]
This report is published simultaneously in the journals Endoscopy and Gastrointestinal Endoscopy. Copyright 2014 © by Georg Thieme Verlag KG and © by the American Society for Gastrointestinal Endoscopy
!
Preparation for capsule endoscopy The major role of video capsule endoscopy (VCE) as a method of imaging the small bowel has been established. However, limitations have also been reported, including quality of the small-bowel images and incomplete assessment of the small bowel. There is no consensus on the best bowel preparation for VCE, and no evidence that preparation with different prokinetics (erythromycin, metoclopramide) or purgative agents [1], or different timings of purgative administration [2] improves the image quality or diagnostic yield in the small bowel. Lubiprostone is a new selective activator of type 2 chloride channels in the apical membrane of the gastrointestinal epithelium. Previous studies have reported net fluid secretion and acceleration of small-bowel and colonic transit times with lubiprostone [3], although other studies have not confirmed the results [4]. A short, double-blind, placebo-controlled study from Japan [5] evaluated the usefulness of lubiprostone for both smallbowel preparation and as a propulsive agent to improve the transit of the capsule endoscope. The study volunteers received the drug and/or placebo at 60 and 30 minutes before VCE ingestion in three groups: a 24-μg lubiprostone tablet followed by placebo (L-P group); placebo followed by 24 μg lubiprostone (P-L group); and placebo followed by placebo (P-P group). The outcome measures were the gastric and small-bowel transit times, the adequacy of cleansing, and the amount of water in the small bowel (measured by median image quality score). The use of lubiprostone significantly decreased the small-bowel
Crohn’s disease The evaluation of the small bowel is crucial in patients with Crohn’s disease in order to differentiate the disease from other enteropathies and for making decisions about therapy and follow-up. VCE is the first diagnostic choice for small-bowel exploration. Its usefulness has been established for the diagnosis of Crohn’s disease, the definition of extent and activity of the disease, and to confirm or to exclude complications such as tumors. The main advantage of VCE is the ability to visualize the entire small bowel. However, its main drawback is the inability to perform biopsy and therapeutic procedures. The complementary procedure for selected patients who require biopsy or therapy is deep enteroscopy. The insertion route for deep enteroscopy (antegrade/oral or retrograde/anal approach) can be chosen according to VCE findings. In examinations for suspected Crohn’s disease, a negative conventional endoscopy with ileoscopy may involve an unexplored area of the small bowel (jejunum and ileum) with disease involvement in approximately 15 % of cases (i. e. false-negative cases). Deep entero-
Pérez-Cuadrado Martínez Enrique, Pérez-Cuadrado Robles Enrique. Capsule endoscopy and deep enteroscopy … Endoscopy 2014; 46: 787–790
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Capsule endoscopy and deep enteroscopy
DDW Highlights
scopy is an invasive procedure, but offers a high diagnostic accuracy. The VCE is a noninvasive procedure with high sensitivity for detecting early superficial lesions and therefore has a special position in the diagnostic algorithm after ileocolonoscopy. However, among patients with known Crohn’s disease, the indication of VCE for the diagnosis of small-bowel lesions is unclear. A multicenter study from Portugal [6] analyzed the clinicobiological features and endoscopic findings associated with lesions in the proximal small bowel in patients with known Crohn’s disease who underwent VCE. Most of the 158 patients were diagnosed between the ages of 17 and 40 years (Montreal classification A2, 74 %), with ileal location (L1, 42 %), and nonstricturing, nonpenetrating phenotype (B1, 74 %). Inflammatory activity was detected in the proximal two-thirds of the small bowel in 34 % of patients. In the univariate analysis, predictive factors with statistical significance for proximal small-bowel involvement were stricturing behavior, high C-reactive protein levels, high platelet count, and significant weight loss. Older age (> 40 years), and low albumin and protein levels were protective for inflammatory activity at VCE in this location. These basic clinical data could help to select the best candidates with Crohn’s disease to undergo VCE for diagnosis of proximal small-bowel lesions. It would be interesting to know the influence of these factors in patients with a more aggressive phenotype than those included in this study. The diagnostic yield of VCE in Crohn’s disease is generally higher than classical radiologic imaging techniques, but for magnetic resonance enterography (MRE) the data are scarce and inconclusive. No previous studies have compared VCE with MRE. The advantage of MRE is the capability to evaluate transmural involvement in Crohn’s disease. VCE and MRE are considered to be complementary techniques. A comparative trial from Spain [7] included 55 patients with established (n = 43) or suspected (n = 9) Crohn’s disease and 3 patients with indeterminate colitis. All patients initially underwent MRE to rule out strictures, followed by VCE. A patency capsule was administered in the seven patients with suspected strictures on MRE, and this was retrieved with no modifications in 100 % of cases. Small-bowel lesions were found in 46 patients by VCE and in 22 patients by MRE (83.6 % vs. 45.5 %; P < 0.05). Concordance between presence or absence of lesions was 58 % (32/55 patients). VCE detected lesions in the proximal and mid small bowel in 16 patients who had negative MRE explorations. Lesions in the terminal ileum were diagnosed by VCE in 46 patients and by MRE in 24 patients (83.6 % vs. 43.6 %; P = 0.03). The authors concluded that VCE is superior to MRE for detection of lesions in the proximal and mid small bowel in Crohn’s disease.
Deep enteroscopy !
Current recommendations issued by scientific societies for the study of the small bowel are based on the high degree of accumulated evidence on flexible endoscopy and VCE exploration [8].
Total enteroscopy Double-balloon enteroscopy (DBE), which was introduced 13 years ago [9], replaced intraoperative and push enteroscopy (with or without overtube) as the reference standard examination in the small bowel, allowing examination of the whole small bowel either via the antegrade route or by a combined antegrade and retrograde approach. In contrast to push enteroscopy, in which the force is only transmitted through pushing, DBE incor-
porates the concept of pushing and pulling, with simultaneous traction on the overtube and enteroscope with inflated balloons, which rectify and fold the small-bowel loops while the enteroscope advances. A method has been proposed by the Wiesbaden group for determining the DBE distance reached [10], and this has been validated recently by other groups [11]. The most commonly used practice for complete small-bowel exploration by DBE is a combined route, tattooing the distal end reached with the first approach, which is then identified during the examination by the second route [8]. Although the VCE travels along the entire digestive tract, allowing the whole small bowel to be viewed during a single examination, detected lesions cannot always be located accurately. As a general rule, if the point to be reached is observed during the first 60 % of the small-bowel examination time, subsequent DBE access should be via the antegrade route; if the target is observed during the last 40 % then the retrograde route is used. The degree of concordance between VCE and DBE in obscure gastrointestinal bleeding (OGIB) is high for vascular and inflammatory lesions but only moderate for neoplastic lesions and polyps in previous multicenter studies [12]. DBE with total small-bowel exploration as the gold standard should be used to validate VCE findings. A study from the United States [13] defined the diagnostic values of VCE and small-bowel radiographic imaging in smallbowel diseases such as Crohn’s disease, OGIB, and submucosal masses, using total enteroscopy with DBE as the gold standard. Of 1840 patients, 239 underwent total DBE small-bowel exploration, 46 of which were performed in one direction (antegrade ap" Fig. 1). A total DBE was performed in 34 patients with proach) (● known or suspected Crohn’s disease. Five cases were newly diagnosed with Crohn’s disease after DBE. The sensitivity of VCE for Crohn’s disease was high (80 %) compared with radiographic imaging (46 %), but specificity was low at 37 %. Among the 119 patients with OGIB, the sensitivity of VCE was 80 % for OGIB-occult and 70 % for OGIB-overt, whereas for radiographic imaging the sensitivity was much lower (17 % and 38 %, respectively). This higher sensitivity of VCE could be due to easy identification of angiectasia, which is the most common lesion in OGIB. Additionally, for OGIB-occult the combination of VCE plus imaging had a positive predictive value (PPV) of 80 % compared with 40 % for imaging alone. In 53 patients with submucosal masses detected by VCE and/or total DBE, a much higher sensitivity was observed compared with radiographic imaging methods. However, the PPV of the radiographic methods for submucosal masses was higher (90 %) compared with VCE (70 %). The authors concluded that total enteroscopy can accurately diagnose Crohn’s disease, etiology of OGIB, and true submucosal masses. VCE has a high sensitivity for identifying small-bowel Crohn’s disease but low specificity. VCE has a high sensitivity compared with imaging for OGIB and should be the second diagnostic step after standard endoscopy.
Enteroscopic diagnostic yield The first-line examination for OGIB is VCE, and in some cases other noninvasive studies are required, such as computed tomography enterography (CTE), before DBE is indicated. However, there is a paucity of data regarding how often these tests alter management plans and whether a positive result on VCE or CTE increases the diagnostic yield of DBE. In a single-center study [14], 102 patients with OGIB were evaluated by antegrade DBE only (n = 53), retrograde DBE only (n = 18), or both (n = 31). The overall diagnostic yield of antegrade and retrograde DBE was
Pérez-Cuadrado Martínez Enrique, Pérez-Cuadrado Robles Enrique. Capsule endoscopy and deep enteroscopy … Endoscopy 2014; 46: 787–790
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
788
DDW Highlights
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Fig. 2
67 % and 69 %, respectively. Prior to DBE, 50 (49 %) and 58 (57 %) patients underwent CTE and VCE, respectively. A total of 27 patients (26 %) underwent both CTE and VCE prior to DBE, with study agreement noted in 6 patients (22 %). The overall diagnostic yield of CTE and VCE was 30 % and 71 %, respectively. In the 83 patients who underwent pre-DBE imaging (CTE, VCE, or both), a potential source lesion was identified by DBE in 58 cases (70 %). The diagnostic yield of DBE was 56 % (14/25 patients) when preDBE imaging was negative and 79 % (46/58 patients) when preDBE imaging was positive. In the 19 patients without pre-DBE imaging, a source lesion was identified during DBE in 16 cases (84 %). In the 83 patients with pre-DBE imaging, a lesion outside the reach of antegrade DBE was identified in 16 cases (19 %), 8 of which (50 %) were identified by pre-DBE imaging as being accessible only by retrograde DBE. In conclusion, the overall diagnostic yield of antegrade DBE is superior to CTE and roughly equivalent to VCE in the evaluation of OGIB. Although the diagnostic yield of DBE is higher when pre-DBE imaging is positive, a source lesion is frequently identified when pre-DBE imaging is negative or not performed.
Therapeutic enteroscopy The therapeutic capability of DBE means that surgery may be avoided. The outcome and safety of DBE for the removal of foreign bodies lodged in the small bowel was investigated in a large retrospective study from a single tertiary center [15], which included 22 patients undergoing 33 DBEs. The most common foreign " Fig. 2), followed by body was a capsule endoscope (n = 12) (● distally migrated biliary or pancreatic stents (n = 5) and accidental or intentional ingestion of foreign bodies (spoon, nail, fish hook; n = 5). Only seven patients had known underlying medical conditions affecting the small bowel (three with Crohn’s disease and three with previous surgery). DBE also newly diagnosed four additional patients with small-bowel Crohn’s disease, seven nonsteroidal anti-inflammatory drug-induced strictures, and one anastomotic stricture. DBE was successful in extracting the foreign body in 19 patients (86 %) but failed in three patients (14 %), and in one patient (3 %) the procedure was complicated by smallbowel perforation. This study, which is the largest study on DBE for the removal of foreign bodies lodged in the small bowel, sug-
Capsule endoscope impaction in a Crohn’s disease stenosis.
gests that DBE can be used as a first-line attempt at retrieval before an indication for surgery.
Enteroscopy complications The causal mechanism of acute pancreatitis after oral DBE is still uncertain. Several recent studies have shown a mechanical or vascular alteration on the pancreas in a porcine model during this exploration [16]. The presence of ischemic pancreatic necrosis in half of the animals on pathologic analysis at necropsy supports the ischemic etiology. Hyperamylasemia and hyperlipasemia after DBE are frequent and are usually asymptomatic, without the development of acute pancreatitis. In a prospective study from the Czech Republic [17], several laboratory markers were evaluated to predict patients at higher risk of hyperamylasemia and hyperlipasemia and/or possible DBE-associated acute pancreatitis. A total of 38 patients who underwent 44 DBEs (mean time 80 minutes) and 30 matched, healthy controls who did not undergo endoscopy, were included. Laboratory markers, including serum C-reactive protein, amylase, and lipase, were measured before, and 4 and 24 hours after DBE, and once in controls. Serum amylase and lipase levels increased significantly and peaked at 4 hours after DBE, with abnormal values in 31/44 (70 %) and 29/44 (66 %) of patients, respectively (both P < 0.001). No other clinically relevant differences were observed between laboratory measures before and after DBE or compared with healthy controls. This study supports the previous hypothesis of this Czech group, that the enteroscope induces mechanical straining on the pancreas during DBE, and it is the most important factor responsible for the observed increases in amylase and lipase and for the progression to acute pancreatitis. However, the authors found no predictive laboratory markers that would identify in advance those patients with a higher risk. Competing interests: None
References 1 Pons Beltrán V, González Suárez B, González Asanza C et al. Evaluation of different bowel preparations for small bowel capsule endoscopy: a prospective, randomized, controlled study. Dig Dis Sc 2011; 56: 2900 – 2905 2 Black K, Truss W, Joiner C et al. Single-center randomized controlled trial evaluating timing of preparation for capsule enteroscopy upon diagnostic yield. Gastrointest Endosc 2013; 77: AB172
Pérez-Cuadrado Martínez Enrique, Pérez-Cuadrado Robles Enrique. Capsule endoscopy and deep enteroscopy … Endoscopy 2014; 46: 787–790
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Fig. 1 Total smallbowel enteroscopy by antegrade route.
DDW Highlights
3 Camilleri M, Bharucha AE, Ueno R et al. Effect of a selective chloride channel activator, lubiprostone, on gastrointestinal transit, gastric sensory, and motor functions in healthy volunteers. Am J Physiol Gastrointest Liver Physiol 2006; 290: G942 – 947 4 Hooks SB3rd, Rutland TJ, Di Palma J et al. Lubiprostone neither decreases gastric and small-bowel transit time nor improves visualization of small bowel for capsule endoscopy: a double-blind, placebo-controlled study. Gastrointest Endosc 2009; 70: 942 – 946 5 Matsuura M, Iida H, Nonaka T. Lubiprostone decreases small-bowel transit time and improves visualization of the small bowel in capsule endoscopy: a double-blind, placebo-controlled 3-way crossover study. Gastroenterology 2014; 146: 358 6 Rodrigues S, Cardoso H, Rosa B et al. Predictive factors of proximal small bowel Crohn’s disease detected at capsule endoscopy. Gastroenterology 2014; 146: 233 7 Diaz-Gonzalez A, Rodríguez S, Rodriguez de Miguel C et al. Capsule endoscopy is superior to magnetic resonance enterography for the assessment of small bowel lesions in Crohn’s disease patients: a comparative trial. Gastroenterology 2014; 146: 383 8 Pérez-Cuadrado E, Pons V, Bordas JM et al. Small bowel endoscopic exploration. Spanish GI Endoscopy Society recommendations (flexible enteroscopy and capsule endoscopy). Endoscopy 2012; 44: 979 – 987 9 Yamamoto H, Sekine Y, Sato Y et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001; 53: 216 – 220
10 May A, Nachbar L, Schneider M et al. Push-and-pull enteroscopy using the double-balloon technique: method of assessing depth of insertion and training of the enteroscopy technique using the Erlangen EndoTrainer. Endoscopy 2005; 37: 66 – 70 11 López Albors O, Soria F, Pérez Cuadrado E. Validity of insertion depth measurement in double-balloon endoscopy. Endoscopy 2012; 44: 1045 – 1050 12 Marmo R, Rotondano G, Casetti T et al. Degree of concordance between double-balloon enteroscopy and capsule endoscopy in obscure gastrointestinal bleeding: a multicenter study. Endoscopy 2009; 41: 587 – 592 13 Mann NK, Jamil LH, Lo SK et al. Total enteroscopy should be used to validate capsule endoscopy and other imaging technologies of the small intestine. Gastroenterology 2014; 146: 39 14 Law R, Hansel SL, Fidler JL et al. Assessment of multi-modality evaluations of obscure gastrointestinal bleeding. Gastroenterology 2014; 146: 40 15 Bartel MJ, Stauffer J, Kroner T et al. Lodged foreign bodies in the small bowel –proceed to surgery or perform double balloon enteroscopy first? Gastroenterology 2014; 146: 1051 16 Latorre R, Soria F, López-Albors O et al. Effect of double-balloon enteroscopy on pancreas: an experimental porcine model. World J Gastroenterol 2012; 18: 5181 – 5187 17 Kopacova M, Bures J, Rejchrt S. Laboratory predictors of hyperamylasemia and hyperlipasemia after double balloon enteroscopy. Gastroenterology 2014; 146: 767
Pérez-Cuadrado Martínez Enrique, Pérez-Cuadrado Robles Enrique. Capsule endoscopy and deep enteroscopy … Endoscopy 2014; 46: 787–790
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
790
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787
Authors
Enrique Pérez-Cuadrado Martínez, Enrique Pérez-Cuadrado Robles
Institution
Small Bowel Unit, Digestive Service, Morales Meseguer Hospital, Murcia, Spain
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1377448 Published online: 18.8.2014 Endoscopy 2014; 46: 787–790 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X
During the 2014 Digestive Disease Week in Chicago, many high-quality studies on small-bowel endoscopy were presented. The most relevant abstracts from around the world of two comple-
mentary procedures – capsule endoscopy and deep enteroscopy – which have seen rapid changes in recent years, have been selected for this review.
Capsule endoscopy
transit time (178.5, 110.5, and 122.5 minutes in the P-P, P-L, and L-P groups, respectively). In addition, lubiprostone was effective in inducing water secretion into the small bowel (1 ± 1.65, 4 ± 1.29, and 4 ± 1.64 in the P-P, P-L, and L-P groups, respectively; P < 0.01), and improved the visualization of the small bowel during VCE (3 ± 1.35, 4 ± 0.85, and 4 ± 0.56 in the P-P, P-L, and L-P groups, respectively; P < 0.01). Studies that include more patients are needed to determine whether or not the lubiprostone with or without various purgative prokinetics improves the diagnostic yield of VCE.
Corresponding author Enrique Pérez-Cuadrado Martínez, MD Hospital Morales Meseguer (U. Endoscopia) c/Marqués de los Vélez SN 30008 Murcia Spain Fax: +34-968-359777 [email protected]
This report is published simultaneously in the journals Endoscopy and Gastrointestinal Endoscopy. Copyright 2014 © by Georg Thieme Verlag KG and © by the American Society for Gastrointestinal Endoscopy
!
Preparation for capsule endoscopy The major role of video capsule endoscopy (VCE) as a method of imaging the small bowel has been established. However, limitations have also been reported, including quality of the small-bowel images and incomplete assessment of the small bowel. There is no consensus on the best bowel preparation for VCE, and no evidence that preparation with different prokinetics (erythromycin, metoclopramide) or purgative agents [1], or different timings of purgative administration [2] improves the image quality or diagnostic yield in the small bowel. Lubiprostone is a new selective activator of type 2 chloride channels in the apical membrane of the gastrointestinal epithelium. Previous studies have reported net fluid secretion and acceleration of small-bowel and colonic transit times with lubiprostone [3], although other studies have not confirmed the results [4]. A short, double-blind, placebo-controlled study from Japan [5] evaluated the usefulness of lubiprostone for both smallbowel preparation and as a propulsive agent to improve the transit of the capsule endoscope. The study volunteers received the drug and/or placebo at 60 and 30 minutes before VCE ingestion in three groups: a 24-μg lubiprostone tablet followed by placebo (L-P group); placebo followed by 24 μg lubiprostone (P-L group); and placebo followed by placebo (P-P group). The outcome measures were the gastric and small-bowel transit times, the adequacy of cleansing, and the amount of water in the small bowel (measured by median image quality score). The use of lubiprostone significantly decreased the small-bowel
Crohn’s disease The evaluation of the small bowel is crucial in patients with Crohn’s disease in order to differentiate the disease from other enteropathies and for making decisions about therapy and follow-up. VCE is the first diagnostic choice for small-bowel exploration. Its usefulness has been established for the diagnosis of Crohn’s disease, the definition of extent and activity of the disease, and to confirm or to exclude complications such as tumors. The main advantage of VCE is the ability to visualize the entire small bowel. However, its main drawback is the inability to perform biopsy and therapeutic procedures. The complementary procedure for selected patients who require biopsy or therapy is deep enteroscopy. The insertion route for deep enteroscopy (antegrade/oral or retrograde/anal approach) can be chosen according to VCE findings. In examinations for suspected Crohn’s disease, a negative conventional endoscopy with ileoscopy may involve an unexplored area of the small bowel (jejunum and ileum) with disease involvement in approximately 15 % of cases (i. e. false-negative cases). Deep entero-
Pérez-Cuadrado Martínez Enrique, Pérez-Cuadrado Robles Enrique. Capsule endoscopy and deep enteroscopy … Endoscopy 2014; 46: 787–790
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Capsule endoscopy and deep enteroscopy
DDW Highlights
scopy is an invasive procedure, but offers a high diagnostic accuracy. The VCE is a noninvasive procedure with high sensitivity for detecting early superficial lesions and therefore has a special position in the diagnostic algorithm after ileocolonoscopy. However, among patients with known Crohn’s disease, the indication of VCE for the diagnosis of small-bowel lesions is unclear. A multicenter study from Portugal [6] analyzed the clinicobiological features and endoscopic findings associated with lesions in the proximal small bowel in patients with known Crohn’s disease who underwent VCE. Most of the 158 patients were diagnosed between the ages of 17 and 40 years (Montreal classification A2, 74 %), with ileal location (L1, 42 %), and nonstricturing, nonpenetrating phenotype (B1, 74 %). Inflammatory activity was detected in the proximal two-thirds of the small bowel in 34 % of patients. In the univariate analysis, predictive factors with statistical significance for proximal small-bowel involvement were stricturing behavior, high C-reactive protein levels, high platelet count, and significant weight loss. Older age (> 40 years), and low albumin and protein levels were protective for inflammatory activity at VCE in this location. These basic clinical data could help to select the best candidates with Crohn’s disease to undergo VCE for diagnosis of proximal small-bowel lesions. It would be interesting to know the influence of these factors in patients with a more aggressive phenotype than those included in this study. The diagnostic yield of VCE in Crohn’s disease is generally higher than classical radiologic imaging techniques, but for magnetic resonance enterography (MRE) the data are scarce and inconclusive. No previous studies have compared VCE with MRE. The advantage of MRE is the capability to evaluate transmural involvement in Crohn’s disease. VCE and MRE are considered to be complementary techniques. A comparative trial from Spain [7] included 55 patients with established (n = 43) or suspected (n = 9) Crohn’s disease and 3 patients with indeterminate colitis. All patients initially underwent MRE to rule out strictures, followed by VCE. A patency capsule was administered in the seven patients with suspected strictures on MRE, and this was retrieved with no modifications in 100 % of cases. Small-bowel lesions were found in 46 patients by VCE and in 22 patients by MRE (83.6 % vs. 45.5 %; P < 0.05). Concordance between presence or absence of lesions was 58 % (32/55 patients). VCE detected lesions in the proximal and mid small bowel in 16 patients who had negative MRE explorations. Lesions in the terminal ileum were diagnosed by VCE in 46 patients and by MRE in 24 patients (83.6 % vs. 43.6 %; P = 0.03). The authors concluded that VCE is superior to MRE for detection of lesions in the proximal and mid small bowel in Crohn’s disease.
Deep enteroscopy !
Current recommendations issued by scientific societies for the study of the small bowel are based on the high degree of accumulated evidence on flexible endoscopy and VCE exploration [8].
Total enteroscopy Double-balloon enteroscopy (DBE), which was introduced 13 years ago [9], replaced intraoperative and push enteroscopy (with or without overtube) as the reference standard examination in the small bowel, allowing examination of the whole small bowel either via the antegrade route or by a combined antegrade and retrograde approach. In contrast to push enteroscopy, in which the force is only transmitted through pushing, DBE incor-
porates the concept of pushing and pulling, with simultaneous traction on the overtube and enteroscope with inflated balloons, which rectify and fold the small-bowel loops while the enteroscope advances. A method has been proposed by the Wiesbaden group for determining the DBE distance reached [10], and this has been validated recently by other groups [11]. The most commonly used practice for complete small-bowel exploration by DBE is a combined route, tattooing the distal end reached with the first approach, which is then identified during the examination by the second route [8]. Although the VCE travels along the entire digestive tract, allowing the whole small bowel to be viewed during a single examination, detected lesions cannot always be located accurately. As a general rule, if the point to be reached is observed during the first 60 % of the small-bowel examination time, subsequent DBE access should be via the antegrade route; if the target is observed during the last 40 % then the retrograde route is used. The degree of concordance between VCE and DBE in obscure gastrointestinal bleeding (OGIB) is high for vascular and inflammatory lesions but only moderate for neoplastic lesions and polyps in previous multicenter studies [12]. DBE with total small-bowel exploration as the gold standard should be used to validate VCE findings. A study from the United States [13] defined the diagnostic values of VCE and small-bowel radiographic imaging in smallbowel diseases such as Crohn’s disease, OGIB, and submucosal masses, using total enteroscopy with DBE as the gold standard. Of 1840 patients, 239 underwent total DBE small-bowel exploration, 46 of which were performed in one direction (antegrade ap" Fig. 1). A total DBE was performed in 34 patients with proach) (● known or suspected Crohn’s disease. Five cases were newly diagnosed with Crohn’s disease after DBE. The sensitivity of VCE for Crohn’s disease was high (80 %) compared with radiographic imaging (46 %), but specificity was low at 37 %. Among the 119 patients with OGIB, the sensitivity of VCE was 80 % for OGIB-occult and 70 % for OGIB-overt, whereas for radiographic imaging the sensitivity was much lower (17 % and 38 %, respectively). This higher sensitivity of VCE could be due to easy identification of angiectasia, which is the most common lesion in OGIB. Additionally, for OGIB-occult the combination of VCE plus imaging had a positive predictive value (PPV) of 80 % compared with 40 % for imaging alone. In 53 patients with submucosal masses detected by VCE and/or total DBE, a much higher sensitivity was observed compared with radiographic imaging methods. However, the PPV of the radiographic methods for submucosal masses was higher (90 %) compared with VCE (70 %). The authors concluded that total enteroscopy can accurately diagnose Crohn’s disease, etiology of OGIB, and true submucosal masses. VCE has a high sensitivity for identifying small-bowel Crohn’s disease but low specificity. VCE has a high sensitivity compared with imaging for OGIB and should be the second diagnostic step after standard endoscopy.
Enteroscopic diagnostic yield The first-line examination for OGIB is VCE, and in some cases other noninvasive studies are required, such as computed tomography enterography (CTE), before DBE is indicated. However, there is a paucity of data regarding how often these tests alter management plans and whether a positive result on VCE or CTE increases the diagnostic yield of DBE. In a single-center study [14], 102 patients with OGIB were evaluated by antegrade DBE only (n = 53), retrograde DBE only (n = 18), or both (n = 31). The overall diagnostic yield of antegrade and retrograde DBE was
Pérez-Cuadrado Martínez Enrique, Pérez-Cuadrado Robles Enrique. Capsule endoscopy and deep enteroscopy … Endoscopy 2014; 46: 787–790
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
788
DDW Highlights
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Fig. 2
67 % and 69 %, respectively. Prior to DBE, 50 (49 %) and 58 (57 %) patients underwent CTE and VCE, respectively. A total of 27 patients (26 %) underwent both CTE and VCE prior to DBE, with study agreement noted in 6 patients (22 %). The overall diagnostic yield of CTE and VCE was 30 % and 71 %, respectively. In the 83 patients who underwent pre-DBE imaging (CTE, VCE, or both), a potential source lesion was identified by DBE in 58 cases (70 %). The diagnostic yield of DBE was 56 % (14/25 patients) when preDBE imaging was negative and 79 % (46/58 patients) when preDBE imaging was positive. In the 19 patients without pre-DBE imaging, a source lesion was identified during DBE in 16 cases (84 %). In the 83 patients with pre-DBE imaging, a lesion outside the reach of antegrade DBE was identified in 16 cases (19 %), 8 of which (50 %) were identified by pre-DBE imaging as being accessible only by retrograde DBE. In conclusion, the overall diagnostic yield of antegrade DBE is superior to CTE and roughly equivalent to VCE in the evaluation of OGIB. Although the diagnostic yield of DBE is higher when pre-DBE imaging is positive, a source lesion is frequently identified when pre-DBE imaging is negative or not performed.
Therapeutic enteroscopy The therapeutic capability of DBE means that surgery may be avoided. The outcome and safety of DBE for the removal of foreign bodies lodged in the small bowel was investigated in a large retrospective study from a single tertiary center [15], which included 22 patients undergoing 33 DBEs. The most common foreign " Fig. 2), followed by body was a capsule endoscope (n = 12) (● distally migrated biliary or pancreatic stents (n = 5) and accidental or intentional ingestion of foreign bodies (spoon, nail, fish hook; n = 5). Only seven patients had known underlying medical conditions affecting the small bowel (three with Crohn’s disease and three with previous surgery). DBE also newly diagnosed four additional patients with small-bowel Crohn’s disease, seven nonsteroidal anti-inflammatory drug-induced strictures, and one anastomotic stricture. DBE was successful in extracting the foreign body in 19 patients (86 %) but failed in three patients (14 %), and in one patient (3 %) the procedure was complicated by smallbowel perforation. This study, which is the largest study on DBE for the removal of foreign bodies lodged in the small bowel, sug-
Capsule endoscope impaction in a Crohn’s disease stenosis.
gests that DBE can be used as a first-line attempt at retrieval before an indication for surgery.
Enteroscopy complications The causal mechanism of acute pancreatitis after oral DBE is still uncertain. Several recent studies have shown a mechanical or vascular alteration on the pancreas in a porcine model during this exploration [16]. The presence of ischemic pancreatic necrosis in half of the animals on pathologic analysis at necropsy supports the ischemic etiology. Hyperamylasemia and hyperlipasemia after DBE are frequent and are usually asymptomatic, without the development of acute pancreatitis. In a prospective study from the Czech Republic [17], several laboratory markers were evaluated to predict patients at higher risk of hyperamylasemia and hyperlipasemia and/or possible DBE-associated acute pancreatitis. A total of 38 patients who underwent 44 DBEs (mean time 80 minutes) and 30 matched, healthy controls who did not undergo endoscopy, were included. Laboratory markers, including serum C-reactive protein, amylase, and lipase, were measured before, and 4 and 24 hours after DBE, and once in controls. Serum amylase and lipase levels increased significantly and peaked at 4 hours after DBE, with abnormal values in 31/44 (70 %) and 29/44 (66 %) of patients, respectively (both P < 0.001). No other clinically relevant differences were observed between laboratory measures before and after DBE or compared with healthy controls. This study supports the previous hypothesis of this Czech group, that the enteroscope induces mechanical straining on the pancreas during DBE, and it is the most important factor responsible for the observed increases in amylase and lipase and for the progression to acute pancreatitis. However, the authors found no predictive laboratory markers that would identify in advance those patients with a higher risk. Competing interests: None
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Fig. 1 Total smallbowel enteroscopy by antegrade route.
DDW Highlights
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