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Assistant Professor of Medicine. University of Marylan

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Title: Assistant Professor of Medicine. University of Marylan


1
Wireless Capsule Endoscopy In Crohns Disease
  • Eric Goldberg, M.D.
  • Director of VA GI Endoscopy
  • Assistant Professor of Medicine
  • University of Maryland Medical Center
  • November 19th, 2005

2
Capsule Endoscopy for IBD
  • SS is a 40 year old male with a past medical
    history of ulcerative colitis s/p total
    proctocolectomy with ileostomy for dysplasia.
    Post operative course complicated by an SBO
    requiring small bowel resection.
  • SS did well for 11 years following his colectomy
    but then developed bright red blood in his
    ileostomy bag and abdominal pain.
  • Ileoscopy Normal
  • EGD Normal
  • SBFT Normal

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Small Bowel Follow Through
7
Evaluation of the Small Intestine
  • Push Enteroscopy
  • 2.5meter long push enteroscopy
  • Sonde and rope-way enteroscopy
  • CT Enterography
  • Small Bowel MRIs
  • Intra-operative enteroscopy
  • Double Balloon Enteroscopy

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The Capsule
  • Diameter 11mm Length 26mm
  • Optical dome Intestinal illumination by white
    light emitting diodes (LEDs)
  • Lens
  • Complementary metal-oxide silicone imager (color
    camera chip)
  • Transmitter
  • Two batteries (silver oxide)

10
Features of the Capsule
  • Capsule takes two images per second
  • On average, 50,000 images are obtained during an
    8 hour exam
  • Magnification 8x
  • Capsule coating non-adherant
  • Disposable

11
Physiologic Endoscopy
  • Bowel is visualized in its normal state
  • No scope trauma
  • Air insufflation not a factor
  • Exam can be performed on anticoagulation

12
GE Junction
Duodenum
Jejunum
Ileocecal Valve
13
Phlebectasia
AVM
Lymphangectasia
Bleeding Lesion
14
Lymphoma
GIST
Polypoid Mass
Polyp
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NSAID stricture
Radiation Enteritis
Sprue
Villous Drop Out
16
Performance
  • Overnight 12 hour fast
  • Sensors placed on patient
  • Patient wears a belt that contains a battery pack
    and data recorder.
  • Patient ingests capsule around 8am
  • Patient may have clears two hours after ingestion
  • Patient may have a light lunch 4 hours after
    ingestion
  • Avoid other patients who ingested a capsule.
  • Patient returns 7-8 hours later

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Indications
  • Obscure gastrointestinal bleeding
  • Evaluation of extent of small intestinal
    disorders such as Crohns disease or Celiac sprue
  • Abnormal small intestinal imaging
  • Suspected malabsorption
  • Surveillance of polyposis syndromes involving
    small intestine

18
Complications
  • Retention of capsule 1-5
  • Bowel obstruction .5
  • Aspiration Rare

19
Contraindications
  • Absolute
  • Suspected small intestinal obstruction
  • Pacemakers/AICDs.
  • Pregnancy
  • Relative
  • Motility disturbances Gastroparesis/Achalasia
  • Small bowel diverticulosis
  • Poor surgical candidates

20
Informed Consent
  • WCE does not replace examination of the stomach
    or colon
  • Risk includes bowel obstruction that may require
    surgery
  • No MRIs until capsule has passed
  • May not visualize the entire small bowel

21
Average Transit Times
  • Stomach One hour
  • Small Intestine 4 hours
  • Capsule Passage 2-3 days

22
Reading the Study
  • Reading times can vary from 20 minutes to 2 hours
  • Can read up to 25 frames/sec. I recommend 12-15
    frames/second
  • Gadgets to speed reading times
  • Red finding software
  • Double frame imaging
  • Quad view

23
Why Perform Wireless Capsule Endoscopy for IBD?
  • Diagnosis
  • Differentiate UC from Crohns disease
  • Different natural history
  • Different medical and surgical therapies
  • Evaluate extent of small intestinal involvement
  • Determine disease activity

24
Subtle Findings
  • White tipped villi - a sign of inflammatory or
    infiltrative change
  • Q-tip lesion

25
Ileitis
Inflammatory polyp
Crohns disease
Linear Erosions
26
Capsule Endoscopy for Initial Diagnosis of
Crohns Disease Literature Review
  • Four prospective, comparative trials evaluating
    capsule endoscopy for suspected Crohns disease
  • Yield as high as 70 if typical symptoms and
    abnormal inflammatory markers (CRP, ESR)
  • Yield low (lt10) if diarrhea or abdominal pain in
    absence of inflammatory markers/signs.

27
Capsule Endoscopy is Superior to SBFT For the
Evaluation of Crohns Disease
  • Author N SBFT Yield CE Yield
  • Scapa 2002 13 0 46
  • Fireman 2003 17 0 71
  • Herrerias 2003 21 0 43
  • Hara 2005 17 0 71
  • Mow 2004 50 32 60
  • Arguelles 2004 12 0 59
  • SantAnna 2005 20 0 60

Patients with strictures by SBFT were excluded
likely accounting for low yields of SBFT
28
Capsule Endoscopy Versus Other Imaging Modalities
for Crohns Disease
  • Study Yield
  • Capsule vs Ileoscopy 61 vs 46
  • Capsule vs Push enterosc 51 vs 7
  • Capsule vs CT enterography 75 vs 37
  • Capsule vs Small bowel MRI 60 vs 40

29
Safety of Capsule Endoscopy in Crohns Disease
  • Author Patients Capsule Retention
  • Mow 50 4
  • Herrerias 21 0
  • Fireman 17 0
  • Eliakim 20 0
  • SantAnna 20 5
  • Buchman 30 6.7

30
Safety of Capsule Endoscopy in Crohns Disease
  • Recommendations
  • Obtain SBFT prior to CE in patients with known
    Crohns disease to r/o high grade stricture
  • Patency capsule?
  • Discuss and document risks with patients prior to
    capsule
  • Double Balloon Enteroscopy for capsule removal

31
Problems with Current Studies on CE and Crohns
Disease
  • No gold standard diagnostic test to compare
    capsule with
  • Criteria for diagnosing Crohns by capsule
    endscopy
  • Specificity too high?

32
Patient
  • XX is a 32 year old female with a history of
    Crohns disease for ten years. Eight years ago,
    she underwent a terminal ileal resection with an
    ileo-transverse colon anastomosis.
  • For the past 6 months, she was experiencing 4-6
    loose stools per day and mid abdominal pain. She
    denied obstructive symptoms such as nausea,
    vomiting or obstipation.
  • She was being treated with pentasa 3 grams/d and
    enterocort
  • Laboratory evaluation was significant for an ESR
    of 55
  • A SBFT was normal
  • A colonoscopy was normal to the terminal ileum

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Proposed Algorithm For Diagnosis of Suspected
Crohns Disease

Colonoscopy/Ileoscopy
Stop
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Obstructive Symptoms?
_

Capsule Endoscopy
SBFT

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Stop
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