Letters to the editor
Jamie S. Barkin, MD, MACP, MACG, FASGE, AGAF Division of Gastroenterology University of Miami Miller School of Medicine Miami, Florida, USA Division of Gastroenterology Mount Sinai Medical Center Miami Beach, Florida, USA REFERENCES 1. Rondonotti E, Herrerias JM, Pennazio M, et al. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc 2005;62:712-6. 2. Westerhof J, Weersma RK, Koornstra JJ. Risk factors for incomplete small-bowel capsule endoscopy. Gastrointest Endosc 2009;69: 74-80. 3. Tatar EL, Shen EH, Palance AL, et al. Clinical utility of wireless capsule endoscopy: experience with 200 cases. J Clin Gastroenterol 2006;40: 140-4. 4. Delvaux M, Gay G. Capsule endoscopy: technique and indications. Best Pract Res Clin Gastroenterol 2008;22:813-37. 5. Eliakim R, Fireman Z, Gralnek IM, et al. Evaluation of the PillCam colon capsule in the detection of colonic pathology: results of the first multicenter, prospective, comparative study. Endoscopy 2006;38: 963-70. http://dx.doi.org/10.1016/j.gie.2013.12.018
Technology status evaluation report on wireless capsule endoscopy To the Editor: I read with great interest the comprehensive technology status evaluation report on wireless capsule endoscopy by Wang et al for the American Society for Gastrointestinal Endoscopy (ASGE).1 I would like to congratulate the authors and comment on certain parts of their report. Wang et al state that several studies suggest a beneficial effect of full and/or partial bowel preparation on improving the quality of small-bowel visualization. In fact, since the first ASGE technology report in 2006,2 a few meta-analyses have examined this issue, and there is now solid evidence in favor of the use of low-dose (2 L) polyethylene glycol for enhanced quality of visualization in small-bowel capsule endoscopy (SBCE).3-5 The current model of the esophageal capsule system (PillCam ESO2; Given Imaging Ltd, Yoqneam, Israel) has indeed a battery life of 30 to 35 minutes, hence neither as long as 8 hours (as hinted in Table 1 of the study by Wang et al) nor as short as 20 minutes (ie, the working time of its predecessor, PillCam ESO1, which should be considered obsolete). The described ingestion protocol6 for PillCam ESO resulted in highly variable esophageal transit times between 6 and 1200 seconds,7 with a mean esophageal transit time of 189 seconds. Pendlebury et al,8 in an attempt to enhance imaging of the gastric cavity, 872 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5 : 2014
further modified this protocol. Hence, an extra stage was added that involved the patient lying flat and then rolling onto the left and right sides for 2 minutes each. Despite that, effective visualization of the esophagus and gastroesophageal junction remained an issue, prompting the development of a simplified ingestion protocol (SIP).7,9 According to that protocol, the patient ingests the capsule while lying in the right lateral position. Sips of 15 mL of water are given every 30 seconds from a syringe or through a straw until the capsule enters the stomach. At the time of this writing, I believe that the SIP has been adopted by many centers who provide a regular esophageal capsule endoscopy service. Swallowing difficulties, especially in those who are elderly, frail, or both, should be taken seriously because an adverse event of capsule aspiration in this group has been reported.10,11 The authors mention that small-bowel and delayed gastric times preclude complete examination, and indeed extended capsule battery life should be able to sort out this issue; in the meantime, as we have very recently shown,12 the selective and judicious use of prokinetics (both for capsule ingestion and during SBCE), in combination with other modalities, ie, real-time, purge, or their combination, is instrumental in improving the completion rate of SBCE. In the biggest series of its kind, it has been shown that unidirectional viewing capsule endoscopy has a limited ability to visualize the ampulla of Vater,13 although this is not necessarily the case for capsule endoscopy with double-headed cameras.14,15 Recently, in a systematic review, we confirmed the validity of SBCE in patients with iron-deficiency anemia (IDA) alone.16 In this review, 24 studies with 1960 patients who underwent SBCE for IDA were included. The pooled diagnostic yield of SBCE in 4 selected studies that focused solely on patients with IDA was 66.6% (95% confidence interval, 61.0%-72.3%). In suspected Crohn’s disease (CD), the combined use of wireless capsule endoscopy and fecal calprotectin (FC) is cost-effective. Measurement of FC levels before referral for SBCE is a useful tool to select patients with possible small-bowel CD. In particular, FC above 100 mg/g is a good predictor of positive SBCE findings, whereas FC below 200 mg/g is associated with higher SBCE yield (65%) and has confirmed CD in 50% of cases. Furthermore, it has been shown that Lewis score performs better than Capsule Endoscopy Crohn's Disease Activity Index in describing small-bowel inflammation, especially at FC levels of !100 mg/g.17 Anastasios Koulaouzidis, MD, FRCP The Centre for Liver & Digestive Disorders The Royal Infirmary of Edinburgh Edinburgh, United Kingdom www.giejournal.org
Letters to the editor
REFERENCES 1. ASGE Technology Committee, Wang A, Banerjee S, Barth BA, et al. Wireless capsule endoscopy. Gastrointest Endosc 2013;78: 805-15. 2. Mishkin DS, Chuttani R, Croffie J, et al; Technology Assessment Committee. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 2006;63:539-45. 3. Niv Y. Efficiency of bowel preparation for capsule endoscopy examination: a meta-analysis. World J Gastroenterol 2008;14:1313-7. 4. Rokkas T, Papaxoinis K, Triantafyllou K, et al. Does purgative preparation influence the diagnostic yield of small bowel video capsule endoscopy? A meta-analysis. Am J Gastroenterol 2009;104: 219-27. 5. Belsey J, Crosta C, Epstein O, et al. Meta-analysis: efficacy of small bowel preparation for small bowel video capsule endoscopy. Curr Med Res Opin 2012;28:1883-90. 6. Sharma VK, Eliakim R, Sharma P, et al. ICCE consensus for esophageal capsule endoscopy. Endoscopy 2005;37:1060-4. 7. Waterman M, Gralnek IM. Capsule endoscopy of the esophagus. J Clin Gastroenterol 2009;43:605-12. 8. Pendlebury J, Douglas S, Plevris JN. Wireless oesophageal video capsule endoscopy: preliminary experience in seven patients. Gut 2006;55:Suppl A65. 9. Gralnek IM, Rabinovitz R, Afik D, et al. A simplified ingestion procedure for esophageal capsule endoscopy: initial evaluation in healthy volunteers. Endoscopy 2006;38:913-8. 10. Koulaouzidis A, Pendlebury J, Douglas S, et al. Aspiration of video capsule: rare but potentially life-threatening complication to include in your consent form. Am J Gastroenterol 2009;104:1602-3. 11. Lucendo AJ, González-Castillo S, Fernández-Fuente M, et al. Tracheal aspiration of a capsule endoscope: a new case report and literature compilation of an increasingly reported complication. Dig Dis Sci 2011;56:2758-62. 12. Koulaouzidis A, Giannakou A, Yung DE, et al. Do prokinetics influence the completion rate in small-bowel capsule endoscopy? A systematic review and meta-analysis. Curr Med Res Opin 2013;29:1171-85. 13. Koulaouzidis A, Plevris JN. Detection of the ampulla of Vater in small bowel capsule endoscopy: experience with two different systems. J Dig Dis 2012;13:621-7. 14. Karagiannis S, Dücker C, Dautel P, et al. Identification of the duodenal papilla by colon capsule endoscope. Z Gastroenterol 2010;48:753-5. 15. Triantafyllou K, Papanikolaou IS, Papaxoinis K, et al. Two cameras detect more lesions in the small-bowel than one. World J Gastroenterol 2011;17:1462-7. 16. Koulaouzidis A, Rondonotti E, Giannakou A, et al. Diagnostic yield of small-bowel capsule endoscopy in patients with irondeficiency anemia: a systematic review. Gastrointest Endosc 2012;76:983-92. 17. Koulaouzidis A, Douglas S, Rogers MA, et al. Fecal calprotectin: a selection tool for small bowel capsule endoscopy in suspected IBD with prior negative bi-directional endoscopy. Scand J Gastroenterol 2011;46:561-6.
for GAVE. This adverse event has not been reported previously. A 67-year-old woman with Child’s A cirrhosis had recurrent episodes of bleeding caused by GAVE not responding to treatments with argon plasma coagulation. Three previous RFA treatments were done with a continued need for transfusion. A fourth RFA was done with a Halo90 catheter (Covidien, Boston, MA). Three pulses were applied to each site in the antrum at 12 J/cm2, and a total of 50 pulses were completed. The patient complained of several days of nausea and abdominal discomfort after the procedure. Seventeen days after ablation, she presented with fever and altered mental status, and sepsis was diagnosed. Blood cultures grew Streptococcus intermedius. Infective endocarditis and spontaneous bacterial peritonitis were ruled out, and no other source of infection was identified on abdominal imaging. She received 5 days of intravenous daptomycin and imipenem, followed by oral amoxicillinclavulanic acid with resolution of sepsis. We suspect our patient’s infection was related to mucosal injury caused by RFA for GAVE. Our patient’s sepsis was caused by an organism that is a typical commensal of the upper aerodigestive tract, and the illness shortly followed the RFA. Bacterial translocation can occur with polypectomy3 or argon plasma coagulation in the colon.4 Thermal injury with RFA causes mucosal ulceration,5 and S intermedius bacteremia has been previously described in patients with mucosal disruption of the GI tract.6 Cirrhosis may also play a role in the facilitation of bacterial translocation.7 Bacteremia and sepsis should be recognized as an important, albeit rare, adverse event of RFA therapy for GAVE. Irphan Gaslightwala, MD David L. Diehl, MD, FACP, FASGE Department of Gastroenterology and Nutrition Geisinger Medical Center Danville, Pennsylvania, USA REFERENCES
We read with interest the case series of radiofrequency ablation (RFA) for gastric antral vascular ectasia (GAVE).1 We have used this technique with excellent results.2 We recently encountered a case of bacteremia after RFA
1. McGorisk T, Krishnan K, Keefer L, et al. Radiofrequency ablation for refractory gastric antral vascular ectasia (with video). Gastrointest Endosc 2013;78:584-8. 2. Raza N, Diehl DL. Radiofrequency ablation of treatment-refractory gastric antral vascular ectasia (GAVE). Surg Lap Endosc Percut Techn (in press). 3. Bac DJ, van Blankenstein M, de Marie S, et al. Peritonitis following endoscopic polypectomy in a peritoneal dialysis patient: the need for antibiotic prophylaxis. Infection 1994;22:220-1. 4. Pinto Marques P, Carvalho D. Bacterial peritonitis following endoscopic treatment of cecal vascular ectasia in a patient on ambulatory peritoneal dialysis. J Port Gastroenterol 2006;13:284-6. 5. Ganz RA, Utley DS, Stern RA, et al. Complete ablation of esophageal epithelium with a balloon-based bipolar electrode: a phased evaluation in the porcine and in the human esophagus. Gastrointest Endosc 2004;60:1002-10. 6. Bert F, Bariou-Lancelin M, Lambert-Zechovsky N. Clinical significance of bacteremia involving the “Streptococcus milleri” group: 51 cases and review. Clin Infect Dis 1998;27:385-7.
www.giejournal.org
Volume 79, No. 5 : 2014 GASTROINTESTINAL ENDOSCOPY 873
http://dx.doi.org/10.1016/j.gie.2013.12.033
Bacteremia and sepsis after radiofrequency ablation of gastric antral vascular ectasia To the Editor:
Jamie S. Barkin, MD, MACP, MACG, FASGE, AGAF Division of Gastroenterology University of Miami Miller School of Medicine Miami, Florida, USA Division of Gastroenterology Mount Sinai Medical Center Miami Beach, Florida, USA REFERENCES 1. Rondonotti E, Herrerias JM, Pennazio M, et al. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc 2005;62:712-6. 2. Westerhof J, Weersma RK, Koornstra JJ. Risk factors for incomplete small-bowel capsule endoscopy. Gastrointest Endosc 2009;69: 74-80. 3. Tatar EL, Shen EH, Palance AL, et al. Clinical utility of wireless capsule endoscopy: experience with 200 cases. J Clin Gastroenterol 2006;40: 140-4. 4. Delvaux M, Gay G. Capsule endoscopy: technique and indications. Best Pract Res Clin Gastroenterol 2008;22:813-37. 5. Eliakim R, Fireman Z, Gralnek IM, et al. Evaluation of the PillCam colon capsule in the detection of colonic pathology: results of the first multicenter, prospective, comparative study. Endoscopy 2006;38: 963-70. http://dx.doi.org/10.1016/j.gie.2013.12.018
Technology status evaluation report on wireless capsule endoscopy To the Editor: I read with great interest the comprehensive technology status evaluation report on wireless capsule endoscopy by Wang et al for the American Society for Gastrointestinal Endoscopy (ASGE).1 I would like to congratulate the authors and comment on certain parts of their report. Wang et al state that several studies suggest a beneficial effect of full and/or partial bowel preparation on improving the quality of small-bowel visualization. In fact, since the first ASGE technology report in 2006,2 a few meta-analyses have examined this issue, and there is now solid evidence in favor of the use of low-dose (2 L) polyethylene glycol for enhanced quality of visualization in small-bowel capsule endoscopy (SBCE).3-5 The current model of the esophageal capsule system (PillCam ESO2; Given Imaging Ltd, Yoqneam, Israel) has indeed a battery life of 30 to 35 minutes, hence neither as long as 8 hours (as hinted in Table 1 of the study by Wang et al) nor as short as 20 minutes (ie, the working time of its predecessor, PillCam ESO1, which should be considered obsolete). The described ingestion protocol6 for PillCam ESO resulted in highly variable esophageal transit times between 6 and 1200 seconds,7 with a mean esophageal transit time of 189 seconds. Pendlebury et al,8 in an attempt to enhance imaging of the gastric cavity, 872 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5 : 2014
further modified this protocol. Hence, an extra stage was added that involved the patient lying flat and then rolling onto the left and right sides for 2 minutes each. Despite that, effective visualization of the esophagus and gastroesophageal junction remained an issue, prompting the development of a simplified ingestion protocol (SIP).7,9 According to that protocol, the patient ingests the capsule while lying in the right lateral position. Sips of 15 mL of water are given every 30 seconds from a syringe or through a straw until the capsule enters the stomach. At the time of this writing, I believe that the SIP has been adopted by many centers who provide a regular esophageal capsule endoscopy service. Swallowing difficulties, especially in those who are elderly, frail, or both, should be taken seriously because an adverse event of capsule aspiration in this group has been reported.10,11 The authors mention that small-bowel and delayed gastric times preclude complete examination, and indeed extended capsule battery life should be able to sort out this issue; in the meantime, as we have very recently shown,12 the selective and judicious use of prokinetics (both for capsule ingestion and during SBCE), in combination with other modalities, ie, real-time, purge, or their combination, is instrumental in improving the completion rate of SBCE. In the biggest series of its kind, it has been shown that unidirectional viewing capsule endoscopy has a limited ability to visualize the ampulla of Vater,13 although this is not necessarily the case for capsule endoscopy with double-headed cameras.14,15 Recently, in a systematic review, we confirmed the validity of SBCE in patients with iron-deficiency anemia (IDA) alone.16 In this review, 24 studies with 1960 patients who underwent SBCE for IDA were included. The pooled diagnostic yield of SBCE in 4 selected studies that focused solely on patients with IDA was 66.6% (95% confidence interval, 61.0%-72.3%). In suspected Crohn’s disease (CD), the combined use of wireless capsule endoscopy and fecal calprotectin (FC) is cost-effective. Measurement of FC levels before referral for SBCE is a useful tool to select patients with possible small-bowel CD. In particular, FC above 100 mg/g is a good predictor of positive SBCE findings, whereas FC below 200 mg/g is associated with higher SBCE yield (65%) and has confirmed CD in 50% of cases. Furthermore, it has been shown that Lewis score performs better than Capsule Endoscopy Crohn's Disease Activity Index in describing small-bowel inflammation, especially at FC levels of !100 mg/g.17 Anastasios Koulaouzidis, MD, FRCP The Centre for Liver & Digestive Disorders The Royal Infirmary of Edinburgh Edinburgh, United Kingdom www.giejournal.org
Letters to the editor
REFERENCES 1. ASGE Technology Committee, Wang A, Banerjee S, Barth BA, et al. Wireless capsule endoscopy. Gastrointest Endosc 2013;78: 805-15. 2. Mishkin DS, Chuttani R, Croffie J, et al; Technology Assessment Committee. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 2006;63:539-45. 3. Niv Y. Efficiency of bowel preparation for capsule endoscopy examination: a meta-analysis. World J Gastroenterol 2008;14:1313-7. 4. Rokkas T, Papaxoinis K, Triantafyllou K, et al. Does purgative preparation influence the diagnostic yield of small bowel video capsule endoscopy? A meta-analysis. Am J Gastroenterol 2009;104: 219-27. 5. Belsey J, Crosta C, Epstein O, et al. Meta-analysis: efficacy of small bowel preparation for small bowel video capsule endoscopy. Curr Med Res Opin 2012;28:1883-90. 6. Sharma VK, Eliakim R, Sharma P, et al. ICCE consensus for esophageal capsule endoscopy. Endoscopy 2005;37:1060-4. 7. Waterman M, Gralnek IM. Capsule endoscopy of the esophagus. J Clin Gastroenterol 2009;43:605-12. 8. Pendlebury J, Douglas S, Plevris JN. Wireless oesophageal video capsule endoscopy: preliminary experience in seven patients. Gut 2006;55:Suppl A65. 9. Gralnek IM, Rabinovitz R, Afik D, et al. A simplified ingestion procedure for esophageal capsule endoscopy: initial evaluation in healthy volunteers. Endoscopy 2006;38:913-8. 10. Koulaouzidis A, Pendlebury J, Douglas S, et al. Aspiration of video capsule: rare but potentially life-threatening complication to include in your consent form. Am J Gastroenterol 2009;104:1602-3. 11. Lucendo AJ, González-Castillo S, Fernández-Fuente M, et al. Tracheal aspiration of a capsule endoscope: a new case report and literature compilation of an increasingly reported complication. Dig Dis Sci 2011;56:2758-62. 12. Koulaouzidis A, Giannakou A, Yung DE, et al. Do prokinetics influence the completion rate in small-bowel capsule endoscopy? A systematic review and meta-analysis. Curr Med Res Opin 2013;29:1171-85. 13. Koulaouzidis A, Plevris JN. Detection of the ampulla of Vater in small bowel capsule endoscopy: experience with two different systems. J Dig Dis 2012;13:621-7. 14. Karagiannis S, Dücker C, Dautel P, et al. Identification of the duodenal papilla by colon capsule endoscope. Z Gastroenterol 2010;48:753-5. 15. Triantafyllou K, Papanikolaou IS, Papaxoinis K, et al. Two cameras detect more lesions in the small-bowel than one. World J Gastroenterol 2011;17:1462-7. 16. Koulaouzidis A, Rondonotti E, Giannakou A, et al. Diagnostic yield of small-bowel capsule endoscopy in patients with irondeficiency anemia: a systematic review. Gastrointest Endosc 2012;76:983-92. 17. Koulaouzidis A, Douglas S, Rogers MA, et al. Fecal calprotectin: a selection tool for small bowel capsule endoscopy in suspected IBD with prior negative bi-directional endoscopy. Scand J Gastroenterol 2011;46:561-6.
for GAVE. This adverse event has not been reported previously. A 67-year-old woman with Child’s A cirrhosis had recurrent episodes of bleeding caused by GAVE not responding to treatments with argon plasma coagulation. Three previous RFA treatments were done with a continued need for transfusion. A fourth RFA was done with a Halo90 catheter (Covidien, Boston, MA). Three pulses were applied to each site in the antrum at 12 J/cm2, and a total of 50 pulses were completed. The patient complained of several days of nausea and abdominal discomfort after the procedure. Seventeen days after ablation, she presented with fever and altered mental status, and sepsis was diagnosed. Blood cultures grew Streptococcus intermedius. Infective endocarditis and spontaneous bacterial peritonitis were ruled out, and no other source of infection was identified on abdominal imaging. She received 5 days of intravenous daptomycin and imipenem, followed by oral amoxicillinclavulanic acid with resolution of sepsis. We suspect our patient’s infection was related to mucosal injury caused by RFA for GAVE. Our patient’s sepsis was caused by an organism that is a typical commensal of the upper aerodigestive tract, and the illness shortly followed the RFA. Bacterial translocation can occur with polypectomy3 or argon plasma coagulation in the colon.4 Thermal injury with RFA causes mucosal ulceration,5 and S intermedius bacteremia has been previously described in patients with mucosal disruption of the GI tract.6 Cirrhosis may also play a role in the facilitation of bacterial translocation.7 Bacteremia and sepsis should be recognized as an important, albeit rare, adverse event of RFA therapy for GAVE. Irphan Gaslightwala, MD David L. Diehl, MD, FACP, FASGE Department of Gastroenterology and Nutrition Geisinger Medical Center Danville, Pennsylvania, USA REFERENCES
We read with interest the case series of radiofrequency ablation (RFA) for gastric antral vascular ectasia (GAVE).1 We have used this technique with excellent results.2 We recently encountered a case of bacteremia after RFA
1. McGorisk T, Krishnan K, Keefer L, et al. Radiofrequency ablation for refractory gastric antral vascular ectasia (with video). Gastrointest Endosc 2013;78:584-8. 2. Raza N, Diehl DL. Radiofrequency ablation of treatment-refractory gastric antral vascular ectasia (GAVE). Surg Lap Endosc Percut Techn (in press). 3. Bac DJ, van Blankenstein M, de Marie S, et al. Peritonitis following endoscopic polypectomy in a peritoneal dialysis patient: the need for antibiotic prophylaxis. Infection 1994;22:220-1. 4. Pinto Marques P, Carvalho D. Bacterial peritonitis following endoscopic treatment of cecal vascular ectasia in a patient on ambulatory peritoneal dialysis. J Port Gastroenterol 2006;13:284-6. 5. Ganz RA, Utley DS, Stern RA, et al. Complete ablation of esophageal epithelium with a balloon-based bipolar electrode: a phased evaluation in the porcine and in the human esophagus. Gastrointest Endosc 2004;60:1002-10. 6. Bert F, Bariou-Lancelin M, Lambert-Zechovsky N. Clinical significance of bacteremia involving the “Streptococcus milleri” group: 51 cases and review. Clin Infect Dis 1998;27:385-7.
www.giejournal.org
Volume 79, No. 5 : 2014 GASTROINTESTINAL ENDOSCOPY 873
http://dx.doi.org/10.1016/j.gie.2013.12.033
Bacteremia and sepsis after radiofrequency ablation of gastric antral vascular ectasia To the Editor:
