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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. v.96 n.1 Madrid ene. 2004

 

ORIGINAL PAPERS


Usefulness of capsule endoscopy in patients with suspected small
bowel disease

A. Caunedo, M. Rodríguez-Téllez, J. M. García-Montes, B. J. Gómez-Rodríguez, J. Guerrero1,
J. M. Herrerías Jr., F. Pellicer and J. M. Herrerías

Department of Gastroenterology. University Hospital Virgen Macarena. Seville, Spain.
1Unidad de Aparato Digestivo. Hospital Civil del INSALUD. Ceuta, Spain

 

ABSTRACT

Aim: to study the usefulness and safety of capsule endoscopy as a diagnostic tool in various small bowel disorders.
Design:
a retrospective analysis of a series of cases.
Material and methods:
between August 2001 and August 2002, 92 capsule endoscopy procedures were performed in 88 patients (53M/39F, age: 43.87 ± 16.78). Indications included:
chronic diarrhea (n = 33); unknown abdominal pain (n = 29); occult gastrointestinal bleeding or iron-deficiency anemia (n = 13); abdominal discomfort in NSAID takers (n = 7); staging of gastrointestinal tumors (n = 4), and asymptomatic controls (n = 2). Previously performed gastroscopy, colonoscopy, and small-bowel follow-through were not conclusive in all patients.
Results: most frequently relevant findings included: jejuno-ileal apthas and ulcerations (29 patients), vascular malformations (13 patients), and intestinal neoplasm (6 patients). The groups with a higher rate of findings related to this indication were occult gastrointestinal bleeding (76.92%) and chronic diarrhea (67.85%), with the lowest rate in the abdominal pain group (34.48%). Therapeutic strategy was directly changed in 36 of 88 patients (40.90%) because of capsule-endoscopic findings. The only observed complication was the failed excretion of one of the capsules because of an unknown ulcerated intestinal stricture.
Conclusions: capsule endoscopy is a safe procedure which can study the entire small bowel, meaning a valuable tool for the management of patients with suggestive signs and symptoms of intestinal disorders.

Key words: Capsule endoscopy. Occult gastrointestinal bleeding. Enteroscopy. Enteroclysis. Chronic diarrhea. Abdominal pain.


Caunedo A, Rodríguez-Téllez M, García-Montes JM, Gómez-Rodríguez BJ, Guerrero J, Herrerías JM Jr, Pellicer F, Herrerías JM. Usefulness of capsule endoscopy in patients with suspected small bowel disease. Rev Esp Enferm Dig 2004; 96: 10-21.


Recibido: 27-01-03.
Aceptado: 29-07-03.

Correspondencia: Juan M. Herrerías. Servicio de Aparato Digestivo (8ª planta). Hospital Universitario Virgen Macarena. Avda. Dr. Fedriani, s/n. 41071 Sevilla. Tel.: 955 008801. Fax: 955 008805. e-mail: jmherrerias@supercable.es

 

INTRODUCTION

Since the inception of endoscopic examinations, physicians have wanted to directly visualize the entire digestive tract, but the endoscopic examination of the small bowel remained elusive because of its long length and complex, looped configuration. Small bowel follow-through, the most commonly used exploration, is not able to demonstrate flat lesions such as angiodysplasia or small mucosal lesions (1). Enteroclysis has been reported to be more accurate than small bowel follow-through, but this difference does not seem to be very significant in comparison with a well-performed barium follow-through (2,3). Additionally, enteroclysis requires a skilled radiologist, causes pain and discomfort, needs sedation, involves more patient radiation, and is expensive and time-consuming (1-3).

Push enteroscopy (PE) may diagnose subtle mucosal lesions, take biopsies, and perform therapeutic procedures, but only reaches a limited part of the small bowel, usually between 50 and 120 cm of the upper jejunum (4-6). In addition, the technique is only available at specialized centers, is uncomfortable for the patient, has to be performed with deep sedation, its results strongly depend on the experience of the endoscopist, and complications appear more often than in upper endoscopy, particularly when an overtube is used (4-6). Sonde enteroscopy has been performed for several years to reach deeper areas of the small bowel. Even with this method a complete enteroscopy was mostly not possible, and several parts of the mucosa were not visible due to uncontrolled movements of the endoscope (7). This technique is also uncomfortable or painful, very time-consuming, and unable to take biopsy samples, and therapeutic interventions are not possible; so the use of this procedure has largely been abandoned. Intraoperative endoscopy, although used with great success, is more invasive and associated with a higher rate of complications (8).

Advances in robotics and miniaturization have recently allowed to develop wireless capsule endoscopy (CE), a small device that may be swallowed by the patient and, in a painless and non-invasive way, provides images of the entire small bowel (9-11). The aim of this study was to expose our one-year experience with the capsule, as well as to analyze the usefulness of wireless endoscopy as a diagnostic tool in different small bowel disorders.

PATIENTS AND METHODS

Patients: from August 30, 2001 to August 30, 2002, 92 capsule endoscopies were performed in 88 patients with various digestive signs and symptoms. Thirty-nine patients were female and 53 male, with an average age of 43.87 ± 16.78 (8-74) years. Indications for CE included: chronic diarrhea (group 1: 33 patients); unexplained abdominal pain (group 2: 29 patients); obscure gastrointestinal bleeding (OGB), and iron-deficiency anemia (group 3: 13 patients); abdominal discomfort in NSAID-takers (group 4: 7 patients); staging for gastrointestinal tumors (group 5: 4 patients); and asymptomatic controls (group 6: 2 patients) (Table I). The seven patients in group 4 are participating in another, yet unfinished trial that studies gastrointestinal damage as induced by NSAIDs.

All patients had previously undergone gastroscopy and colonoscopy, whose findings had not been conclusive. A small bowel follow-through was performed in all patients where stenotic lesions had been ruled out. Contraindications for the M2A capsule included patients with suspected or documented intestinal obstruction or strictures, patients who could not swallow the capsule, patients who were nonsurgical candidates or who refused to entertain the idea of surgery in case of device-induced obstruction, patients with a pacemaker or other implanted electromedical devices, and pregnant women. An informed consent was obtained in all cases before the technique was carried out.

Method: we used an endocopic capsule of 11 x 26 mm (M2ATM Given Imaging®, Yoqneam, Israel) in size that contains a colour camera chip that can take two photographs per second, a white light source, a short focal distance lens, an UHF radio frequency transmitter, an antenna, and two batteries. The displacement of the device through the gut follows the physiological gastrointestinal peristaltic movements and needs no air insufflation. Following a pre-established scheme, we placed eight external sensors on the abdominal wall to collect all the photographs and tape them in a Holter system that the patient carries in a belt. The patient must carry this system during seven-eight hours and does not need to be hospitalised. Once the test is finished, the images collected by the Holter are processed in a computer, where they may be selected and analyzed in detail using a specific software (RAPIDTM).

Technique: patients must abstain from food and drinks for at least 8 hours before capsule endoscopy. Medications were taken not less than 8 hours before procedure onset. Drugs that could delay gastric emptying were avoided until capsule endoscopy was completed. The eight sensor arrays were attached to the abdomen in their correct locations, and the recorder-battery belt was placed around the patient´s waist. After removing the capsule from its blister pack and cheking that the blue light in the data recorder kept on blinking, the capsule was swallowed by the patient with a glass of water. The patient was allowed to go home and advised to neither eat nor drink for 2 hours. The patient could drink liquids after 2 hours and have a light snack after 4 hours. All patients were told to contact immediately their physician in case of abdominal pain or discomfort, vomiting or nausea during the procedure. They were advised not to stay near any powerful electromagnetic field source (like magnetic resonance devices) until the capsule was excreted. Patients returned after 8 hours, the equipment was removed, and the recorder was connected to the workstation, in which images were processed and then viewed in a monitor using the RAPIDTM software. This allows images to be viewed at various speeds, with facilities for pausing and rewinding.

Statistical analysis: the results are shown in percentages or average value ± standard deviation, according to each case.

RESULTS

Capsule endoscopy could be carried out in all 88 patients in the study. In four cases the exploration was repeated. Two patients with gastrointestinal neoplasm (intestinal lymphoma and gastrointestinal stromal tumor) were reviewed after specific therapy (chemotherapy and surgery, respectively). In one patient with obscure gastrointestinal bleeding and delayed gastric emptying, the capsule remained in the stomach 8 hours after ingestion and was excreted five days later. Thus, another CE with the administration of a prokinetic agent was performed 8 days later, and the entire small bowel could be studied. In another case, CE did not transmit images since it reached the stomach. Another CE was performed the following day without any technical problem.

Capsule endoscopy was normal in 11 patients. The most frequent (Table II) findings were those suggestive of Crohn´s disease (focal villous denudation, fissures, ulcerations and aphtas) in 29 patients (Fig. 1), vascular malformations (angiodysplasia, angiomas) in 8 patients (Fig. 2), small bowel neoplasms (polyps, lymphomas, GIST tumor) in 6 cases (Fig. 3), lesions suggestive of intestinal damage caused by NSAIDs (erosions, ulcers, strictures) in 6 patients, lymphoid nodular hyperplasia (3 patients), lymphangiectasia or small chylomas (10 patients), and congestive enteropathy (1 patient).

Gastroduodenal erosions or small ulcers were observed in 8 patients, which were previously demonstrated by gastroscopy in 4 cases. The other 4 patients (all of them with OGB) were diagnosed by CE. Subtle intestinal lesions (edema, slight denudations or focal erythema) were considered a nonspecific enteropathy. Other findings detected in a previous gastroscopy were lesions suggestive of peptic esophagitis (n = 25), esophageal varices (n = 1), non-erosive gastritis and duodenitis (n = 35), and congestive gastropathy (n = 3). The groups with a higher rate of positive findings (defined as findings potentially related to the indication) were OGB (84.6%) and chronic diarrhea (67.85%) (Table III).

The most relevant findings in the chronic abdominal pain group (n = 29) were jejunal and ileal ulcerations, and aphtas suggestive of Crohn´s disease (7 patients), duodenal ulcers (2 patients), nonspecific enteropathy (1 patient), and non-bleeding jejunal angiodysplasia (1 patient).

In the chronic diarrhea group (n = 33), lesions suggestive of small bowel Crohn´s disease were observed in 19 patients (56.6%), and two patients showed findings of nonspecific enteropathy. Several jejunal and ileal nodular lesions with a red periphery and white centre (Fig. 4) were seen in a patient. The findings of a later enteroscopy, together with the histological revision of a specimen from a previous cholecystectomy, made us think of an intestinal ganglioneuromyomatosis. No abnormal findings were detected in 5 patients, and 6 patients only showed findings of little clinical relevance (non-erosive esophagitis, gastritis and duodenitis, or lymphangiectasia).

In the OGB group, 2 patients with hematoquezia, 2 with melena and 9 with chronic iron-deficiency anemia were included. One or more potentially bleeding lesions were identified in ten of thirteen patients (76.9%). The most frequent findings were vascular malformations (n = 4), as well as aphtas, focal denudations, and ulcers consistent with small bowel Crohn´s disease (n = 3), duodenal ulcer (n = 1), lesions suggestive of congestive enteropathy (n = 1), and an ulcerated ileal stricture, probably caused by NSAIDs.

The staging of a known gastrointestinal tumor was the indication for CE in 4 patients: one with a MALT lym-phoma, one with a lymphomatous polyposis (LP), one with a primary small bowel lymphoma (PSBL), and one with a GIST tumor. CE showed a more widespread involvement than was previously known in the patient with PSBL (jejunal implication, not seen in the small bowel follow-through), and demonstrated the persistency of the lesions in this patient after chemotherapy. In the patient with a GIST tumor, CE showed an intestinal mucosa with normal appearance after surgery. In the cases of LP and MALT lymphoma, CE did not detect a more extensive gastrointestinal affectation than already known.

In the group of patients with dyspepsia and chronic intake of NSAIDs, CE detected erosive lesions that were distal to the reach of the gastroscope in 5 out of 7 cases (71.43%). The two first cases in this series were healthy volunteers in order to check the new technique.

The management of the patient was changed by CE in 36 out of 88 patients (40.90%): 29 patients with capsule endoscopy suspected small bowel Crohn´s disease in whom conventional treatment was begun, 6 patients with a potentially treatable bleeding lesion, and one patient with PSBL in whom CE demonstrated a lack of response to the chemotherapy applied, and another cytostatic therapy was administered.

Average total transit time was 7.08 ± 0.99 in the 92 explorations. The cardia was reached in 1.11 ± 1.36 minutes. Cardial, pyloric and ileoceal valve transit times were 1.11 ± 1.36, 59.86 ± 63.97, and 285.79 ± 87.16 minutes, which makes up for an average intestinal transit time of 226.95 ± 83.32 minutes. The device could be swallowed without problems by all the patients.

The spontaneous excretion of the capsule happened in all subjets, except in one NSAID user with chronic iron-deficiency anemia. In this case, CE diagnosed an ileal ulcerated stricture (Fig. 5) that had not been seen in a previous small bowel follow-through, and which caused the retention of the device whitout ill effects. A scheduled laparotomy was carried out three weeks later, where the stricture and the capsule were resected. The histological study showed a focal, subacute inflammation with ulcerations and a non-fibrotic stricture, probably induced by NSAID use. The postoperative course of the patient was uncomplicated, and after 6 months of follow-up she remains asymptomatic and free of anemia.

No other adverse effects were observed during or after the procedure. The ileocecal valve could be seen in every patient, except in the two cases with delayed gastric emptying, and in the patient with an ileal stricture.

DISCUSSION

In spite of the radiological and endoscopic advances of the last decades, the study of the small bowel continues to be in many cases a difficult problem in clinical practice. Regarding OGB, conventional radiological, arteriographic and nuclear techniques identify the bleeding lesion in 20-51% of cases (12-14). PE can reach a diagnosis in 30-50% of those cases in which conventional explorations had not been conclusive (14-16). However, there is still a percentage of patients in whom only an invasive procedure, such as intraoperative enteroscopy, may be diagnostic. In these difficult cases the accuracy of a new non-invasive and painless technique such as CE is proposed.

Although numerous abstracts exist, only two studies designed to compare the effectiveness of CE vs PE in OGB have been published (17,18) to date. In both, CE identified more bleeding lesions than EP, fundamentally at the expense of ileal and distal jejunal lesions, although only in the series by Ell et al. (17) this difference reached statistical significance. In our series CE also achieved a high diagnostic accuracy (76.92%) and, although it was not compared to PE, at least in 5 of 10 patients the potentially bleeding identified lesions were probably beyond the range of PE. These data, although pending confirmation by controlled and randomized trials, seem to endorse the role of CE in OGB (19). In this role it cannot replace PE but may complement it, allowing to select patients with lesions that can be sampled or treated by PE, as well as to rule out the existence of multicentric lesions beyond the reach of PE.

OGB has been the first and more studied indication of CE, but others have been proposed. The accuracy of CE in these new indications is still to be confirmed. In our series, the group of patients with unexplained chronic pain achieved a low diagnostic yield (<35%), so this is a questionable indication for CE in the absence of other signs or symptoms. On the contrary, potentially-related-to-the-indication findings were observed in 67.85% of patients with unexplained chronic diarrhea. Obviously, the diagnostic efficacy of CE in this indication depends on the clinical-biological characteristics of considered patients. Anyway, these preliminary data seem to justify the realization of wider studies to analyze the role of CE in a subset of patients with chronic diarrhea. In our series, the most frequent findings in the chronic diarrhea group were ulcerations and aphtas suggestive of Crohn´s disease (19 of 33 cases). Thus, it is interesting to outline the utility of CE in cases of Crohn´s disease with exclusive jejunal or ileal affectation that could not be diagnosed by means of ileocolonoscopy, small bowel follow-through, or enteroclysis (1). In patients with affectation of the distal jejunum and/or proximal ileon alone, the demonstration of radiological findings and the existence of compatible clinical-biological data are the pillars for diagnosis in Crohn´s disease, and it allows the clinician to establish a specific therapy in most cases despite his inability to have histological confirmation from a difficultly accessible area of the gastrointestinal tract (20-25). However, when due to their nature or precocity lesions are not detected by radiological exams, diagnosis and appropriate treatment are delayed from 2 to 4 years by the lack of an appropriate and non-invasive technique allowing this portion of the small bowel to be studied (1, 25-27).

CE cannot confirm with certainty the suspicion of Crohn´s disease, since it does not allow an anatomo-pathological study, but it can either support or rule out a diagnosis, supposing a valuable additional fact in the clinical and analytic context of these patients in whom obtaining a biopsy of the intestinal lesion would require a surgical procedure (28-31).

The study of tumoral pathology of the small bowel has also been proposed as one of the possible indications of this new technique (32,33), but only some isolated cases have been published to date. In our series, CE allowed to determine the extension of the tumor as well as the response to chemotherapy in one of the cases, with the expected handling implications. The role of CE in small bowel infiltrative tumors would go then from the support of a diagnostic suspicion by the physician, to the performance of the most appropriate sampling technique (34), the staging study (35), or the surveillance of response to therapy (36,37). Some authors (33) have outlined the use of CE in the screening of small bowel follow-through in high-risk patients, as is the case for long-term celiac disease that becomes refractory to diet. However, the inability to obtain biopsy samples, as well as the absence of an unequivocal macroscopic appearance of this type of small bowel lym-phoma (38), limit this indication at present. Anyway, it seems clear that large, controlled and well-designed studies are needed to establish the true indications of one of the most attractive techniques developed in the last years.

Failed capsule excretion is the most prominent complication of this technique, occurring in approximately 0.5% of explorations according to the manufacturer (39), and it usually happens in stenotic areas not detected by radiological studies. Surface and form of the capsule make very unusual an obstructive complication (32,40). This way it happened in our patient, a NSAID using woman with two previous small bowel follow-throughs reported as normal. CE demonstrated an ulcerated ileal stricture that impeded the capsule’s progression, and that was electively resected three weeks later. So, it seems that the previous realization of a small bowel follow-through is necessary but not enough to rule out an intestinal stricture, what forces the physician to emphasize this eventual complication to his patient before CE, as well as to exclude as candidates for this procedure those patients who are nonsurgical candidates or who refuse to entertain the idea of surgery (32,40).

In conclusion, the present study demonstrates that CE is a safe technique able to explore the whole small bowel. In spite of its inability to take biopsies, which represents its main limitation, is a procedure that provides valuable information for the handling of patients with small bowel disorders that could not be diagnosed using conventional methods.

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