Endoscopic Imaging of the Small Bowel

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Endoscopic Imaging of the Small Bowel

• Surinder Mann MD
• Professor of Clinical Medicine
• Director of Small Bowel Endoscopy
• UC Davis Medical Center

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Introduction

• Enteroscopy is defined as direct visualization
  of small bowel with use of fiberoptic or
  wireless endoscope
• Historically due to length and tortuosity of the
  SB , examination has been limited to the most
  proximal and distal aspects
• Complete SB examination was only possible with
  intraoperative enteroscopy.
• Development of newer enteroscopic imaging
  techniques since 2001 , more thorough evaluation
  of SB is possible
• New techniques include CE, BAE ( DBE SBE ),
  Spiral enteroscopy
• Enteroscopy currently has pivotal role in
  evaluation of OGIB, Crohns disease , tumors and
  Celiac Disease
• Leighton JA Am J Gastroenterol 201110627-36

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Game Plan

• The Small Intestine No Longer the Final Frontier
• What is Capsule Endoscopy (CE)?
• Clinical Applications of CE
• Limitations of CE
• Game Changers Indications for CEBAE in OGIB

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Disruptive Technology

• Endoscopic visualization of entire small bowel
• Fiberoptic and wireless endoscopes
• Paradigm shift in workup of OGIB
• Evaluation of Crohns disease, celiac disease,
  small bowel tumors, OGIB

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What is Capsule Endoscopy?

• Allows for direct, noninvasive examination of the
  small bowel without discomfort or sedation
• 26 x 11 mm in size
• Images transmitted wirelessly to data recording
  device
• Gold standard in evaluating small bowel in OGIB

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Clinical Applications of Small Bowel Capsule
Endoscopy (CE)

• Large retrospective and prospective clinical
  studies have proven the superior safety and
  efficacy of CE for the diagnosis of OGIB (Obscure
  GI Bleed)
• CE can be useful in diagnosing small bowel
  tumors/masses
• Although limited, CE appears to be safe and
  useful in the pediatric population

Treister et al. Am J Gastroenterol. 2005
1002407-18 Moglia A et al. Lancet 2007 370
114-116 De Angelis GL. Am J Gastroenterol. 2007
102 1749-1757
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Olympus CE and the Given SB Pillcam Are
Comparable for OGIB

• FDA trial
• Swallowed by the same patient, 40 minutes apart,
  randomized
• Read locally and independently by 2 reviewers
• Overall agreement was 38/51, 74.5, k .48,
• p .008

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Limitations of CE

• Incomplete examinations
• Poor preparations
• Limited mucosal visualization
• Rapid transit through particular segments
• Unidirectional field of view
• Interobserver variability

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The Capsule Does Not Reach the Cecum in 20 of CE

• 100 patients with OGIB
• Prospective, multicenter study
• 2 liters GoLytelyliquid diet day before
• Capsule did not reach cecum in 20 of studies 21
  cases

• Reasons for capsule failure
• Slow gastric passage
• Unsuspected stricture
• Obstructing tumor
• Presence of food
• Technical failure
• No clear reason

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Not Good!
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Capsule Retention Occurs in .75 to 5 of All
Studies

• Most cases occur in small bowel
• Risk factors NSAID use, radiation, Crohn disease
• Other causes retention in diverticulae, tracheal
  aspiration, cricopharyngeus impaction

Pennazio, Endosccopy 2004, 3832-41 Barkin et al.
Am J Gastro 2002, 87 A82
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Indications of Deep Enteroscopy

• Obscure GI Bleeding
• Chronic Diarrhea
• Iron Deficiency Anemia
• Abnormal SBFT/CTE
• Abnormal Capsule Endoscopy
• Peutz-Jegher Polyps
• Refractory Celiac Disease
• Retained Foreign Bodies
• Intestinal Strictures
• Crohns Disease
• Small Bowel polyp removal/Bx/Tatoo

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Unusual Indications

• Mid Gut Carcinoid
• ERCP in Roux-en-Y situations
• Abdominal symptoms in gastric bypass patients
• Protein wasting enteropathy
• Jejunal Stenting
• PEG placement in Gastric bypass anatomy
• Previously failed colonoscopy

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Double Balloon Enteroscopy

• Developed in 2001 ( Yamamoto and colleagues ) and
  in practice US 2004
• DBE is now performed worldwide with diagnostic
  therapeutic options.
• Fujinon system and has diagnostic and therapeutic
  scopes.
• Balloons are mounted at the tip of overtube and
  distal end of scope.

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Single Balloon Enteroscopy

• Olympus SIF- Q 180 Enteroscope
• Length is 200 cm
• Outer diameter 9.2 mm
• Working channel 2.8 mm
• Overtube 132 cm and silicone rubber balloon
  attached to the distal end.
• Outer diametr of overtube 13.2 mm inner
  diameter 11 mm
• 100 Latex free Silicone construction of
  overtube.
• 5.4 kpa Set inflation pressure
• 8.2 kpa Over pressure warning
• -6.2 kpa Set deflation pressure

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Comparison with Double Balloon Enteroscopy

• DBE available 2001- and clinical use in 2004
• SBE availalable 2007
• SBE is simple ( because it only has one balloon
  ), safe and takes 5 minutes to prepare the
  system.DBE takes 15 minutes to prepare the
  system.
• SBE can be performed by single endoscopist using
  standard conscious sedation.
• SBE has intrinsic stiffness and does not require
  the use of a stiffening wire as needed in DBE.
• SBE Overtube/Balloon are silicon rubber and is
  Latex-Free
• DBE can examine more length of SB as compared to
  SBE and DBE also has balloon at the tip of scope.
• Farthest point reached by both DBE/SBE is more
  via oral route than anal route.
• Average procedure for SBE is 54 - 18 minutes
  and for DBE 95 - 41 minutes in antegrade
  procedure.
• Most of the total enteroscopy is not necessary as
  lesions mostly targeted by Capsule endoscopy or
  other imaging studies.
• DBE and SBE have similar array of therapeutics.
• DBE and SBE have similar comlications.
• Presence of varices is considered a
  contraindication.

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Complications

• Sedation related adverse events
• Perforation
• Pancreatitis
• Abdominal pain

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Spiral Enteroscopy

• Newest enteroscope system
• Endo-Ease Discovery SB ( Spirus Medical )
• Spiral shaped overtube 118 cm, hollow spiral is
  5.5 mm high and 22 cm long
• Can be used antegrade or retrograde with
  enteroscope lt9.4 mm in diameter
• Advancement and withdrawal of enteroscope by
  rotatory clockwise and counterclockwise movements
• Distal end of overtube stationed at 25 cm from
  tip of the enteroscope and locked into place
• System is advanced up to ligament of Trietz with
  gentle rotation, collar is unlocked, enteroscope
  is advanced past the ligament of Treitz with
  gentle rotation, collar is now unlocked ,
  overtube is now advanced using clockwise rotation
  until pleating of SB no longer occurs
• Enteroscope is unlocked and now advanced further
  into SB
• Withdrawal of the enteroscope is facilitated by
  rotating the overtube counterclockwise
• Overtube also available for retrograde
  enteroscopy and difficult colonoscopy.
• Preliminary data shows 33 diagnostic yield and
  average depth of 176 cm, another study showed
  262- 5 cm depth of SB achieved
• Severe Complications rate 0.3 and 0.27 SB
  perforation
• GIE 200969327-32

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Lesion Missed on Given Pillcam and Olympus
Capsule!
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Massive Bleeding from GIST Lesion

• 50-yo gentleman with hematochezia
• Colonoscopy full of blood and clots
• Status post 7 u PRBCs
• Hgb at 8 with no change
• WCE blood only
• DBE ulcerated submucosal mass

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Proposed Classification of Mass Lesions per
International Consensus
Mergener K et al, Endoscopy, 2007 30 805
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Approach to Bulges
Leighton J. ACG 2010
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Case Obscure GI Bleeding

• 70-yo gentleman with iron deficiency anemia
• Laboratory evaluation
• Hgb - 8
• Intermittent melena, no abdominal pain
• Endoscopic evaluation
• EGD and colonoscopy normal
• Requires 2u prbcs transfusion every month
• CTE normal

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What Would You Do Next?

• Push enteroscopy
• Second look endoscopy
• Capsule enteroscopy
• Nuclear scan/Angiography
• Hematology consultation
• Intraoperative Enteroscopy
• Meckel scan
• BAE

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What Defines an Obscure GI Bleed?

• Bleeding from the GI tract that persists or
  recurs after an initial negative evaluation using
  bidirectional endoscopy and radiologic imaging
  with barium contrast medium, such as small bowel
  follow through (SBFT) or enteroclysis

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Causes of Obscure GI Bleeding

• No studies to date on either the frequency or
  location
• Within reach of a standard endoscope
• Dependent on age
• Angiectasias account for 30-60 of cases in
  obscure-overt gi bleed
• Upper, mid, lower classification

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Etiology Based on Age

• Older 40 Years
• Angioectasia
• GAVE
• NSAID enteropathy
• Dieulafoy
• Tumors

• Younger than 40 Years
• Tumors
• Crohn disease
• Meckel diverticulum
• Dieulafoy
• Celiac disease

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Exceptions to the Rule!
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Many Lesions that Present as OGIB Are Actually
Missed Lesions Located Within Reach of a Standard
Endoscope

• Aim to determine incidence of lesions within
  reach of a standard endoscope
• 143 DBEs performed in 107 patients for OGIB
• Definite source of bleeding outside the small
  bowel detected in 24.2
• EGD/colonoscopy w/in 1 week
• Most common lesions were diverticula and
  angioectasias in the colon
• If oral DBE negative, then retrograde DBE

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Should I First Perform Capsule Enteroscopy or
Push Enteroscopy to Evaluate the Small Bowel?
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Capsule Endosocopy Doubles the Diagnostic Yield
to That of Push Enteroscopy in Obscure GI Bleeding
Triester et al. A Meta Analysis of the Yield of
Capsule Endoscopy Compared to Other Diagnostic
Modalities in Patients with Obscure
Gastrointestinal Bleeding. Am J Gastroenterol
2005 1002407-2418.
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Capsule Endoscopy Is Far Superior to Small Bowel
Radiography in Obscure GI Bleeding in Terms of
Diagnostic Yield
Triester et al. A Meta Analysis of the Yield of
Capsule Endoscopy Compared to Other Diagnostic
Modalities in Patients with Obscure
Gastrointestinal Bleeding. Am J Gastroenterol
2005 1002407-2418.
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What Can Improve the Diagnostic Yield of CE in
OGIB?

• Patients with hemoglobin lt10 mg/dl
• Longer duration of bleeding (lt6 months)
• Conversion of obscure-occult to overt (46 vs
  60)
• Greater than 4g drop in hemoglobin
• Performance of capsule within 2 weeks of bleeding
  episode (91 vs 34)

Leighton, J. ACG 2010
39
Capsule Enteroscopy Is Currently Recommended as
the Third Test of Choice for OGIB After Negative
EGD and Colonoscopy

• First prospective, randomized study comparing CE
  to PE
• Followed for 1 year
• Cross-over design
• Compared 2 strategies CE first or PE first
• Adjusted Odds Ratio 3.22 in favor of CE first
  strategy

DeLeusse et al. Capsule Endoscopy or Push
Enteroscopy for First-Line Exploration of Obscure
Gastrointestinal Bleeding? Gastroenterology
2007132855-862
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A Positive Capsule Enteroscopy Can Lead to
Improvement in Further Bleeding By Leading to
Definitive Therapy
Pennazio et al. Gastroenterology 2004 126643-653
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DBE Is Favored Over CE in the Setting of OGIB
When Bidirectional

• Meta-analysis of 8 studies comparing yield of CE
  to DBE with the outcome as OR of the yield
• Prospective studies
• No difference in overall yield between CE and DBE
  (OR 1.61, 95 CI 1.07-2.43)
• But CE had significantly lower yield compared to
  DBE using combined antegraderetrograde approach
  (OR 0.12, 95 CI .03-.52, plt.01)

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DBE is Cost-Effective

• Median time to diagnose OGIB 2 years (1 mo - 8
  years)
• Average of 7.3 tests per patient w/half of those
  patients still bleeding
• Costs associated with diagnosing OGIB - 33,360
  per patient
• Case-Base Patient 70-yo man with obscure-overt
  bleed from small bowel angiectasias
• Compared PE, CE-guided DBE, DBE, angiography, IOE
• DBE cost effective and highest success rate for
  bleeding cessation
• CE-guided DBE to be best approach due to resources

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Follow up On Case Study

• Diaphragm strictures per CE and DBE at proximal
  ileum
• Counseled on NSAID cessation all NSAIDs!
• Because of transfusion dependence went for
  surgical resection
• Resolution of anemia

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Take Home Points

• Consider push enteroscopy as part of your second
  look if BAE not readily available
• In most cases of OGIB do CE first
• Use CE as a guide to directing BAE route
• Deep enteroscopy may find bleeding sources not
  detected by CE or other standard tests