The Usefulness of Capsule Endoscopy David J. Hass, MD, FACG - PowerPoint PPT Presentation

The Usefulness of Capsule Endoscopy David J. Hass, MD, FACG Assistant Clinical Professor of Medicine Yale University School of Medicine Gastroenterology Center of Connecticut

Obscure Gastrointestinal Bleeding

ASGE Technology Status Evaluation Report: Efficacy and Comparative Studies Obscure GI Bleeding • “In a recent evaluation of obscure GI bleeding after a negative initial workup, 47 consecutive patients underwent both capsule and intraoperative enteroscopy .” • “Compared with intraoperative enteroscopy, the sensitivity, specificity, and positive and negative predictive value of capsule endoscopy were 95%, 75%, 95%, and 86%, respectively.” Gastrointestinal Endoscopy 2006;63(4):539-545

OGIB – Meta -Analysis • Three studies (n=88 patients) showed a yield for CE of 67% compared to 8% for small bowel radiography • CE is superior to push endoscopy and SB barium radiography for diagnosis clinically significant pathology in patients with OGIB • The incremental yield of CE over these methods is >30% due to visualization of additional vascular and inflammatory lesions 4

• 138 patients were included • CE revealed one or more gastric or small bowel lesions considered to be the cause of IDA in 66% • Complete resolution of IDA was achieved in 76% • CE enables visualization of the entire small bowel, permitting a diagnosis in unexplained IDA and therefore leading to a more targeted treatment 6

AGA Medical Position Statement on Bleeding The American Gastroenterological Association (AGA) Position Statement on Obscure GI Bleeding states that patients with occult blood loss and iron deficiency anemia (IDA) and negative work up on EGD and colonoscopy need comprehensive evaluation, including capsule endoscopy, to identify an intestinal bleeding lesion. Raju GS, et al. (AGA Institute) Gastroenterology 2007; 133:1694- 1696.

Approach to the Patient with Obscure GI Bleeding • Capsule endoscopy is the preferred test for visualizing the mucosa of the entire small bowel • CE should be the next diagnostic tool in patients with obscure bleeding for whom there is no suspected obstruction. • The diagnostic yield of CE is high and has the potential to produce an earlier diagnosis. Faigel, DO and Cave, DR. Capsule Endoscopy. 2008 Elsevier Inc:71-90

Case # 1 • 63 year old woman • Recurrent overt obscure gastrointestinal bleeding • Feels well most days, but with recurrent melena

Case # 1 • PE: Appears well, but fatigued, Slight tachypnea • Lungs clear to auscultation. II/VI systolic ejection murmur • Gross melena noted on rectal examination • Exam otherwise normal

Case # 1 • CBC: 4.5/5.1/15.6/244 MCV:64 • Ferritin 6, Iron saturation 4% • Panel 7: 144/3.8/110/25/70/1.1/87 • Coagulation profile normal • Liver tests unremarkable

Case # 1 • EGD/Colon with ileal intubation negative for overt pathology • Meckel’s scan negative • Tagged RBC scan negative • SBS negative

Case # 1 • Small bowel capsule endoscopy performed…….

Case # 1 • Diagnosis: – Small bowel angioectasias causing obscure overt gastrointestinal bleeding and anemia.

Angioectasias • Most common vascular abnormality of the GI tract • Most frequent cause of recurrent gastrointestinal bleeding • Commonly located in the colon, but can be seen throughout the entire gastrointestinal tract • Bleeding from angioectasias is usually recurrent and low grade, though 15% of patients present with massive hemorrhage

Angioectasias • Treatment options: – Hormonal therapy – Angioembolization – Endoscopic evaluation with push enteroscopy, double balloon enteroscopy coupled with BICAP cauterization or argon plasma coagulation

Case 2

Case 2 • 69-year-old gentleman • Medical history: – Stage IIIb lung adenocarcinoma status post-left lung resection in 2009, positive lymphadenopathy – Status post-adjuvant chemotherapy – History of COPD and heavy past tobacco use • Presentation: – Obscure overt GI bleeding with recurrent melena – Feeling relatively well – Mild fatigue – Mild dyspnea on exertion

Physical Exam • Afebrile, BP: 100/40, HR: 80, RR: 22 • Mildly tachypneic • Decreased breath sounds in L posterior lung field • No appreciable lymphadenopathy • Benign abdominal exam • Rectal exam: – Black loose stool, strongly guaiac positive – No evidence of peri-anal fistula or fissures

Laboratory Profile • CBC: 7.5/6.1/18.6/244, MCV:77 • Ferritin: 5 • Iron saturation: 4% • Normal B12 and folic acid level • Panel 7: 144/3.8/110/25/70/1.1/87 • Normal coagulation profile

Work-up • Colonoscopy with deep ileal intubation: normal • EGD/enteroscopy: normal • Tagged RBC scan: negative • Meckel’s scan: negative

Audience Question #1 How would you proceed in the evaluation of this patient? a) Repeat EGD & colonoscopy b) Angiography c) Capsule endoscopy d) Double balloon enteroscopy e) Stop investigation

Capsule Endoscopy Findings Video

Capsule Endoscopy Findings Video

Capsule Endoscopy Findings

Audience Question #2 What is the next step in this patient’s management? a) Intraoperative enteroscopy with surgical resection b) Double balloon enteroscopy with attempt at removal c) Observation d) Entocort

Follow-up • A subsequent double balloon enteroscopy was performed – Frond-like mass noted in mid-ileum – Pathology consistent with recurrent lung adenocarcinoma • Patient initiated on chemotherapy and stable at present

Metastasis to the Small Bowel • Uncommon but important to keep in the differential diagnosis • Most common metastasis from the following: – Breast – Lung – Melanoma – Thyroid – Renal cell carcinoma

Metastasis to the Small Bowel • Most common presentations of metastatic disease: – Intussusception – Obstruction – Obscure gastrointestinal bleeding

Case # 3 • 20 year old college student • Two week history of intermittent maroon colored stools • No abdominal pain or other constitutional symptoms • Shortness of breath and fatigue

Case #3 • Physical exam: – BP 90/40 HR 110 – Tachycardic, II/VI SEM at LLSB – Otherwise unremarkable – Rectal exam: black tarry stool • CBC: 4.5/5.1/15.6/244 MCV:84 • Panel 7: 144/3.8/110/25/70/1.1/87 • Coagulation profile normal/Liver tests unremarkable

Work-up • Colonoscopy with deep ileal intubation: normal • EGD/enteroscopy: normal • Tagged RBC scan: negative

Case 3: Capsule Endoscopy Findings Video

Case 3: Capsule Endoscopy Findings

Meckel’s Diverticulum • Occur in the distal ileum, 60-90 cm oral to the ileocecal valve • Estimated incidence: – 2% in general population – Equal gender distribution Cullen JJ, Kelly KA, Moir CR, et al. Surgical management of Meckel's diverticulum. An epidemiologic, population-based study. Ann Surg. 1994;220:564-568.

Meckel’s Diverticulum • Diagnosis can be made by 99m Tc scan nuclear imaging – sensitivity of: • 85% in children/ 62% in adults • Meckel’s diverticula encountered by CE or deep enteroscopy may or may not be culprit for bleeding • 50% of these lesions contain heterotopic mucosa

Case # 4 • 58 year old woman, post menopausal • Recurrent overt obscure gastrointestinal bleeding/maroon stools • Several months of fatigue/lethargy

Case # 4 • PE: Appears well, but fatigued, Slight tachypnea • Lungs clear to auscultation. • Guaiac negative rectal examination • Exam otherwise normal

Case # 4 • CBC: 4.5/7.1/22.6/244 MCV:64 • Ferritin 2, Iron saturation 1% • Panel 7: 144/3.5/110/25/44/1.1/87 • Coagulation profile normal • Liver tests unremarkable

Case # 4 • EGD/Colon with ileal intubation negative for overt pathology • Meckel’s scan negative during episode • Tagged RBC scan negative during episode

Audience Question What is the next step in this patient’s management? a) Intraoperative enteroscopy b) Double balloon enteroscopy c) Capsule endoscopy d) Heparin challenge and subsequent investigation

Audience Question What is the next step in this patient’s management? a) Intraoperative enteroscopy b) Double balloon enteroscopy c) Observation d) Angiogram

Case # 4 • Angiogram performed – Negative for extravasation of contrast • Next step?? – Double balloon enteroscopy performed oral route – DX: Dieulafoy lesion in mid jejunum

Case # 4 • Multiple ways to evaluate obscure overt bleeding. • CAPSULE ENDOSCOPY should be third test assuming hemodynamic stability to identify source and then direct therapeutic intervention

Case # 5 • 44 year old Sicilian woman visiting family from Italy presents with iron deficiency anemia • Regular menses, not particularly concerning • Progressive anemia

Case # 5 • PE: Appears well • Guaiac positive rectal examination • Exam otherwise normal

Case # 5 • CBC: 4.5/6.1/18.6/244 MCV:60 • Ferritin 1, Iron saturation 1% • Panel 7: 144/3.5/110/25/33/1.1/87 • Coagulation profile normal • Liver tests unremarkable