Seeing Round the Bend An introduction to capsule Endoscopy

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Seeing Round the BendAn introduction to capsule
Endoscopy
Dr Sameer Zar MBBS, MRCP, PhDConsultant
GastroenterologistEpsom St Helier NHS Trust
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Videocapsule Endoscopy

• Easily ingested, painless procedure
• Progresses naturally through the GI tract
• Disposable capsule (11 x 26 mm)
• Lens (wide angle view 1560)
• LEDs (light emitting diodes)
• CMOS chip (camera)
• Battery, transmitter, antenna
• gt55,000 images

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Videocapsules

• Pill Cam Small Bowel
• Pill Cam ESO
• Pill Cam COLON

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Introduction The Small Bowel

• Accounts for 75 of the total length of the GI
  tract
• Technically difficult to examine due to length of
  small bowel 3-5m tortuousity
• Barium follow through-low diagnostic yield
  particularly in detecting angiodysplasia in
  patients with obscure GI bleeding
• Small bowel enteroclysis yield of 25 in obscure
  GI bleeding
• Videocapsule imaging of the small bowel has
  revolutionised medical practice.

Ginsberg G et al Wireless capsule endoscopy
GastrointestEndosc0256621-4
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Patient selection

• Established Indications
• Emerging Indications
• Potential indications
• No indication
• Contraindication

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Patient selection

• Established Indications
• Emerging Indications
• Potential indications
• No indication
• Contraindication

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Established Indications

• Obscure gastrointestinal bleeding
• Suspected Crohns disease after negative prior
  diagnostic tests

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Gastrointestinal bleeding

• Overt
• haematemesis, melaena, hematochazia)
• Occult
• (pos FOBT, iron deficiency anaemia)
• Obscure (overt or occult)
• No bleeding source at upper and lower GI endoscopy

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Gastrointestinal bleeding

• Upper
• Proximal to Papilla
• Middle
• From Papilla to Ileo-caecal valve
• Lower
• Distal to Ileo-caecal valve

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Meta-Analysis -VCE vs Radiology Diagnostic yield
in obscure bleeding
Triester et al. (2005) Am J Gastroenterol 1002407
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Content
Blood
Coagulum
Hematin
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Angiectasia
Small
Medium
Large
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Angiectasia Arborisation

• Yes
• No

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Angiectasia - Number

• Single
• Few
• Multiple

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Angiectasia

• Number Single / multiple
• Size Small / medium / large
• Arborization Yes / no
• Active Bleeding Yes / no
• Bleeding stigmata Yes / no
• Bleeding potential Yes / possible / no
• Distribution Focal / diffuse

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• VCE
• is the diagnostic method of choice in patients
  with obscure GI bleeding with documented
  therapeutic impact and positive influence on
  outcome

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Established indications

• Obscure gastrointestinal bleeding
• Suspected Crohns disease after negative prior
  diagnostic tests

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Suggestion from ICCE consensus Suspected Crohns
disease

• Patients with at least two criteria
• Abdominal pain or diarrhoea
• Iron deficiency anaemia
• Elevated ESR or CRP
• Hypoalbuminemia
• Extraintestinal manifestations
• Family history of IBD
• Abnormal serologies

Mergener et al. Endoscopy 39895 (2007)
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Crohns Disease VCE vs other tests
Meta Analysis
Triester S et al. Am J Gastroenterol 2006
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Crohns Image spectrum
Erosion, erythema
Aphtha
Ulcers
Ulcer, petechiae
Bleeding
Stenosis
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Isolated colitis

• Small intestinal lesions in VCE
• 9/22 diagnostic
• 4/22 suspicious
• 12/22 Diagnosis changed into suspected Crohns
  disease

Mow et al. 2004 Clin. Gastroenterol Hepatol 231
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ICCE Consensus Established Crohns disease

• CE can be of potential value
• - in the evaluation of indeterminate colitis
• - evaluation of unexplained symptoms of patients
  with known IBD
• CE may have a unique role in assessing
• - mucosal healing after medical therapy
• - for early post-operative recurrence to guide
  therapy

A Kornbluth, J Colombel, J Leighton, E Loftus
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Postsurgical Recurrence of Crohns disease

• 24 asymptomatic patients with ileo-colic
  anastomosis
• 2 excluded for suspected stenosis (by patency
  capsule)
• Recurrence seen at
• Capsule 15 cases
• Colonoscopy 6 cases

Pons et al. Gastrointest Endosc 66533 2007
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Patient selection

• Established Indications
• Emerging Indications
• Potential indications
• No indication
• Contraindication

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Emerging indications

• Complicated coeliac sprue
• Surveillance of patients with polyposis syndromes
  especially Peutz-Jeghers, FAP with duodenal
  adenomas ?
• Indeterminate Colitis
• Documentation of mucosal healing in treatment
  studies in Crohns disease?
• Pathologic imaging studies

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Complicated celiac sprue

• Complicated sprue Pain/diarrhoea in spite of
  gluten free diet, long period without diet,
  history of small intestinal carcinoma or
  lymphoma, anaemia, pos FOBT
• 87 endoscopic signs of celiac sprue
• 45 unexpected findings
• 21 Ulcerations
• 1 Small bowel carcinoma
• 1 Submucosal tumour
• 1 Ulcerated nodular Mucosa
• 1 Polyp
• 1 Stricture
• 1 Intussusception

Culliford et al. (2005) GIE 6255 (n 47)
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Suspected celiac sprue

• Sensitivity 87.5
• Specificity 90.9
• Pos. predictive value 96.5
• Neg. predictive value 71.4

Rondonotti et al. 5thICCE, Boca Raton 2006
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Coeliac disease Diagnosis

• Villous atrophy (duodenum) total/
  subtotal/partial increased number of
  intraepithelial lymphocytes (IEL)
• Antibodies
• Anti-endomysial IgA
• Anti-transglutaminase IgA
• sensitivity/specificity gt 95
• Response (clinical /histological) to a
  gluten-free diet

HLA DQ2/8 difficult case Consensus NIH
2004Consensus 2004
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Celiac Image Spectrum
Absent Villi
Fissuring
Scalloping
Scalloping
Mosaic pattern
Fissuring and ulcer
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Small Bowel Tumours
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Small bowel Tumours

• Are rare (about 6 of GI tumours)
• There are numerous histological types
• VCE can not reliably differentiate between benign
  and malignant tumours
• Indication for VCE is predominantly bleeding
• Abdominal pain often sign of advanced disease

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Benign Tumours

• Ectopic tissues
• Ectopic gastric mucosa
• Ectopic pancreas
• Epithelial tumours
• Adenomas
• Mesenchymal tumours
• Hemangioma
• Lymphangioma
• Leimyoma
• Neurofibroma
• Lipoma
• Fibrolipoma

• Inflammatory lesions
• Inflammatory polyps
• Suture granulomas
• Hyperplasias
• Hyperplastic polyps
• Brunners gland hyperplasia
• Hamartomas
• Hamartomatous polyps (PJS)
• Juvenile polyps

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Endoscopic findings Benign tumours

• Often submucosal
• Mucosa intact, but may have ulceration
• May cause intussusception

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Adenomas

• Whitish
• Flat
• Laterally spreading

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Peutz-Jeghers polyps

• Often pedunculated
• May cause obstruction
• May bleed

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Malignant Tumours

• Adenocarcinoma
• Neuroendocrine tumours
• Gastrointestinal stromal tumours
• Sarcoma
• Lymphomas
• Metastases

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Malignant tumours
Infiltrating
Ulcerating
Stenosing
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Patient selection

• Established Indications
• Emerging Indications
• Potential indications
• No indication
• Contraindication

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Potential Indications?

• Staging of GI lymphoma ?
• Neuroendocrine metastasis Search of primary?
• Intestinal metastasis of malignant melanoma ?
• Single cases of malassimilation ?
• Monitoring of therapy
• Mucosal healing in Crohns disease, intestinal
  transplantation
• stem cell transplantion (GvHD)
• Diagnosis of NSAID enteropathy ?

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Patient selection

• Established Indications
• Emerging Indications
• Potential indications
• No indication
• Contraindication

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No Indication

• Screening
• Abdominal Pain with or without diarrhoea
• Diarrhoea with or without pain
• Constipation
• Bloating
• IBS

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Crohns
IBS
Inflammation
Pain
Diarrhoea
Stenosis
Obstruction
Serology
Coeliac
Bleeding
Tumour
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Capsule for Abdominal pain plus

• Weight loss Odds Ratio 18,6
• Shim et . Scand. J. Gastroenterol 41983 (2006)
• Inflammation Odds Ratio 3,2
• May et al. Endoscopy 39606 (2007)
• (Suspected Crohns disease)
• Diagnostic Yield
• 57 with anaemia / inflammation
• 12.5 without

Valle et al. J Clin Gastroenterol 40692 (2006)
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Tests to perform prior to VCE

• History and physical examination
• Oesophago-Gastro-Duodenoscopy
• Colonoscopy, better Ileo-colonoscopy
• Abdominal ultrasound

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Patient selection

• Established Indications
• Emerging Indications
• Potential indications
• No indication
• Contraindication

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Contraindications
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Patient SelectionTake Home Message

• Prior upper and lower GI endoscopy
• Indication
• Obscure / mid GI bleeding,
• suspected Crohns disease,
• complicated celiac sprue,
• Peutz-Jeghers Syndrome
• Contraindication
• Pregnancy,
• Possible Stenosis without need for surgery,
• MRI with capsule

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The Oesophageal Capsule

• New approach to investigation of the oesophagus
• Patient friendly procedure sedation and recovery
  free
• Simple, easy to use and non-invasive
• Potential screening tool for oesophageal diseases

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The Oesophageal Capsule

• Lie on right side, ingest capsule with sip of
  water, and stay in right side 000 - 700 min
• Drink 15ml sips of water every 30 sec.

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The Oesophageal Capsule

• GORD
• Oesophagitis
• ESEM Endoscopic Suspicion of Oesophageal
  Metaplasia (Barretts oesophagus)

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The Oesophageal Capsule

• Portal hypertension
• Oesophageal varices
• Portal hypertensive gastropathy

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The Colon Capsule
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Colon Capsule Potential Benefits

• Direct visualisation of colon
• No sedation
• No intubation
• No insufflations
• No radiation
• Potential to improve patient compliance for
  screening

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Current Common Screening Methods
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Colonoscope vs PillCam COLON
Polyp (10 mm) at Transverse
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Colonoscope vs PillCam COLON
Ulcerative Colitis
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Colonoscope vs PillCam COLON
Diverticulosis
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Summary of Preparation
Pending verification that colon capsule has
moved out of the stomach with RAPID Access RT
(real-time viewer)
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Push Enteroscopy (PE)

• Allows examination of up to 80120cm beyond the
  ligament of Treitz.
• Complete Upper GI examination completed first.
• Measurements-
• incisors to pylorus after straightening
• maximum length of small bowel reached

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Overtube - rejected

• 10-15cm deeper intubation
• No greater pathological yield
• Risks
• Perforation
• Mucosal trauma/stripping
• Pancreatitis

Wilmer A et al GastrointestClinNorth
Am19966759-76
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The truth about PE !

• Diagnostic yield 12-80 ( highest in obscure GI
  bleeding)
• However in 12-64 of lesions found is within
  reach of a gastroscope.

Chen R, Taylor A, Desmond P ANZ J Surg.200272
215-218 Hayat M, Axon A, OMahonyS Endoscopy
200032 (5)369-372
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Missed lesions seen at Push Enteroscopy
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The Double Balloon (DBE) Kit
Described by Yamamoto in 2001 Push pull
enteroscope
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Double Balloon Enteroscopy (DBE)

• High resolution video endoscope, overtube and two
  balloons attached to tip
• Sequential inflation/ deflation of balloons
  whilst guiding scope reduces looping and allows
  greater access
• Potential for pan SB endoscopy for diagnostic/
  therapeutic purposes

Yamamoto et al Gastrointest Endosc 2001 53
216-20 Yamamoto et al Clin Gastroenterol Hepatol
2004
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Courtesy of Blair Lewis
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DBE Method
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DBE Method
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DBE Method
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DBE Method
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DBE Method
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More on DBE

• Total enteroscopy achieved in 1 session (!) or
  combination of anterograde retrograde DBE
  success rate 42-86
• Diagnostic yield in obscure GI bleeding (OGB)
  72-80

Yamamoto et al ClinGastroenterolHepatol2004 May
et al GastrointestEndosc2005 Heineet al
Endoscopy 2006 Kameda N J Gastroenterol2008
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Comparison CE DBE

• Most studies diagnostic yield of CE and DBE
  comparable
• DBE overcomes limitation of CE-therapeutic
  intervention

Chen World J GastroenterolAug 2007 (meta
analysis) Pasha SF ClinGastroenterolHepatolMarch
2008 (meta analysis)
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Cost effective analysis - comparison of CE DBE
in OGB

• Initial DBE may be least expensive strategy when
  definitive diagnosis/ treatment necessary.
• However capsule directed DBE may be associated
  with better long term outcomes (fewer potential
  complications decreased utilization of
  endoscopic resources)

GersonL, GIE April 11, 2008 SomsoukM
ClinGastroenterolHepatol2008 Jun 6(6)661-70
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DBE Complications

• Rate of complications 0-3.4
• Pancreatitis 0.4 after oral DBE ( or isolated
  elevated amylase)
• Haemorrhage requiring laparotomy after
  polypectomy
• Perforation
• Abdominal pain/ distension fever
• Paralytic ileus
• Intestinal necrosis ( after adrenaline inject)
• Intramural haematoma

Zhonget al Endoscopy 200739208-215 Groenenet al
Endoscopy 20063882-85 MoschlerO Z
Gatsroenterol2008
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Summary

• CE if suspected small bowel disease (provided no
  contra-indication)
• PE reserved for therapeutics ( if within reach).
  Highest yield for obscure GI bleeding.
• DBE to confirm CE findings/ therapeutics (oral/
  anal route depending on site of pathology seen on
  CE).