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Assistant Professor of Medicine. University of Marylan

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Assistant Professor of Medicine. University of Maryland Medical Center. November 19th, 2005 ... SS is a 40 year old male with a past medical history of ... – PowerPoint PPT presentation

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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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6
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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9
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
15
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

17
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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34
Proposed Algorithm For Diagnosis of Suspected
Crohns Disease

Colonoscopy/Ileoscopy
Stop
_
Obstructive Symptoms?
_

Capsule Endoscopy
SBFT

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Stop
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