Utility of video capsule endoscopy in clinical practice, experience at King Faisal Specialist Hospital and Research Center, Riyadh

Background: Video capsule endoscopy (VCE) is a valuable diagnostic tool for the evaluation of the small intestine. Evidence shows that it is effective in the diagnosis of occult bleeding and superficial lesions that are not radiographicallyobserved. We evaluated the efficacy and safety of the capsule endoscopy in the diagnosis and management of the common gastrointestinal disorders.Methods: A retrospective chart review of a total of 326 candidates who have met the inclusion criteria and who underwent VCE from the period from January 2006 till December 2018.Results: The main indication for Video Capsule Endoscopy was small bowel overt gastrointestinal bleeding with 106 cases (32.6%) followed by iron deficiency anemia with 104 cases (32%). Capsule retention rate was observed in 11 cases (3.4%) 4 of which were crohn抯 disease patients (22.2%). Overall diagnostic yield was 36%, 64% for overt gastrointestinal bleeding and 41% for occult gastrointestinal bleeding. The most common reported positive finding was Angiodysplasia in 19.9% of cases, followed by ulcers in 13.8% of cases, followed by polyps in 8.3% of cases and erosions in 8% of cases.Conclusions: Video capsule endoscopy proved to be an essential diagnostic tool in gastrointestinal bleeding. Advantages of VCE include; less labor, higher resolution examination of mucosa, relative safety, and noninvasiveness. On the other hand, it does not offer intervention capabilities when compared with enteroscopy and its interpretation was sometimes difficult and time consuming. Risk of capsule retention remains significant especially in patients suffering from crohn抯 disease.

Management of Suspected Small Bowel Bleeding / 胃肠病学

Gastrointestinal hemorrhage is one of the most common symptoms of small bowel diseases. Gastrointestinal bleeding with normal upper and lower endoscopic results is suspected to be small bowel bleeding. With the advent and development of capsule endoscopy, device-assisted enteroscopy, and radiographic imaging, most of the sources of suspected small bowel bleeding can be identified, thereby corresponding treatment can be performed. The key points for the management of suspected small bowel bleeding are choice of suitable examinations, optimal timing of examinations and ideal therapeutic regimens. In this article, the management of suspected small bowel bleeding was briefly reviewed.

Application and safety of double balloon enteroscopy in patients with small bowel hemorrhage / 中国内镜杂志

Objective To analyze the feasibility and the diagnostic yield of double-balloon enteroscopy (DBE) examinations for small bowel bleeding (SBB). Methods A retrospective analysis was conducted on 52 cases with small bowel bleeding between June 2015 and July 2016,and all was treated with DBE. therapeutic outcome, complications and follow-up were compared. Results The study included 52 patients (28 males and 24 females) with an average age of (51.0 ± 17.0) years (16~82 years) and onset time (8.3 ± 4.0) days (1~14 days) . 25 using oral route and 21 using the anal route, 1 using the colon ifstula route, a combination of using oral and anal (n=4).The bleeding source was identiifed in 40 of 52 patients (76.9%), complication rate was 5.8%(3/52), and rebleeding rate was 16.7%(2/12). The endoscopic treatments included polypectomies (n=5), argon plasma coagulation (APC, n=2), surgical treatment (n=14, 26.9%), and foreign-body extraction (n=1). Patients were diagnosed with the following:tumors (n=9, 17.3%), ulcers (n=9, 17.3%), Crohn’s disease (n=7, 13.5%), polyps (n=5, 9.6%), diverticulum (n=4, 7.7%). Patients with small bowel bleeding were followed up for a mean period of (8.3±2.0) months (range 4~10 months), 2 deaths were dying from small bowel cancer. Conclusions DBE is a safe endoscopic technique for patients with small bowel bleeding and can be safely carried out even after Roux-en-Y operation. Tumors, ulcers and Crohn’s disease are very common causes of SBB. The rebleeding rate after a negative DBE is considerable, especially small bowel vascular lesions.

Capsule Endoscopy for Suspected Small Bowel Bleeding in Patients with Portal Hypertension

BACKGROUND/AIMS: In Korea, limited data are available on small bowel bleeding in patients with portal hypertension. This study reports on the use of capsule endoscopy in cases of suspected small bowel bleeding in patients with portal hypertension. METHODS: Capsule endoscopy was used at our hospital to evaluate small bowel disease in 501 cases from July 2003 to June 2010. Of those cases, nine patients with portal hypertension due to liver cirrhosis with suspected small bowel bleeding were selected for the study. A retrospective analysis was performed using data from medical records. RESULTS: Six of the nine (66.7%) patients were males with an average age of 53.4 years. The average hemoglobin level was 8.1 g/dL. Abnormalities noted during capsule endoscopy included portal hypertensive enteropathy in all nine cases (100%), jejunal varices in four (44.4%), jejunal and ileal angiodysplasia in five (55.5%), multiple small bowel erosions in one (11.1%), granularity of the jejunal mucosa in one (11.1%), and small bowel erythema in three (33.3%). Active bleeding from jejunal varices was detected in two patients (22.2%). Despite having no obvious active bleeding during the capsule endoscopy, four patients (44.4%) were diagnosed with portal hypertensive enteropathy with obscure small bowel bleeding. CONCLUSIONS: Capsule endoscopy is a useful diagnostic tool for the evaluation of small bowel bleeding in patients with portal hypertensive enteropathy. Additional prospective and multicenter studies on the use of capsule endoscopy are needed to evaluate the incidence and clinical importance of portal hypertensive enteropathy.

Follow-up after Double Balloon Enteroscopy in Patients with Suspected Small Bowel Bleeding: Focused on the Rebleeding Rate / 대한소화기내시경학회지

BACKGROUND/AIMS: Double balloon enteroscopy (DBE) is an effective modality for making the diagnosis and managing suspected small bowel bleeding. However, there is limited data on the follow-up results after DBE. The aim of this study was to evaluate the long-term clinical outcome after DBE in patients with suspected small bowel bleeding. METHODS: We retrospectively analyzed the rebleeding rate of 60 consecutive patients (M:F=39:21, age: 13~85 years) who underwent DBE because of suspected small bowel bleeding at Asan Medical Center during a 3 year period. RESULTS: The median follow-up period was 552 days. Bleeding sources were detected by DBE in 41 patients. The cumulative rebleeding rate at 6, 12 and 24 months was 22%, 27% and 30%, respectively. There was no significant difference in the cumulative rebleeding rate between the patients with bleeding sources detected by the initial DBE and those without bleeding sources detected by the initial DBE. The cumulative rebleeding rate at 6 and 12 months was significantly higher for the patients with vascular or superficial mucosal lesions than for the patients with tumors or other lesions (p=0.013). CONCLUSIONS: The rebleeding risk after DBE is not low for patients with suspected small bowel bleeding. The rebleeding risk is especially high for patients with vascular or superficial mucosal lesions, and this may necessitate careful follow-up.

A Case of Capsule Endoscopy in a 42-month-old Girl / 대한소화기내시경학회지

Capsule endoscopy (CE) provides a minimally invasive examination of the entire small intestine, and is the preferred procedure for evaluation of patients with GI bleeding of unknown origin. Even though the FDA approved its use for pediatric patients between 10 and 18 years old in January 2004, little information is available regarding the effectiveness of CE in the younger pediatric population (below 6 years old) because of safety issues. A 42-month child with recurrent melena was referred to evaluate the cause of gastrointestinal bleeding. Despite extensive evaluation, including EGD, colonoscopy, a small bowel series, and Meckel's scan, the bleeding source was not identified. Finally, wireless CE demonstrated angiodysplasia on the mucosa of proximal jejunum. This is the first pediatric case of endoscopy-assisted CE under intravenous sedation without endotracheal intubation in Korea.

Lymphangioma of the Small Intestine with Chronic Gastrointestinal Bleeding

A lymphangioma of the small bowel is a rare benign tumor of the lymphatic system, which generally is non-symptomatic but can develop some complications such as gastrointestinal obstruction or bleeding. A 40-year-old female was admitted to our hospital due to chronic gastrointestinal bleeding of 17 months duration. Endoscopic evaluation, computed tomographic examination of the abdomen and pelvis, angiography and enteroclysis were performed, but no abnormal findings were found. A red blood cell (RBC) scan demonstrated the presence of active bleeding in the upper abdominal area; however, the precise location of the bleeding could not be determined. An exploratory laparotomy was performed, with an approximately 0.4 cm sized polypoid mass detected in the proximal jejunum just distal to the Treitz ligament on an intraoperative endoscopic examination through the incision in the mid-jejunum. A segmental resection of the jejunum containing the bleeding mass and primary anastomosis was performed. The final pathological diagnosis was a lymphangioma of the jejunum. In patients with a non-localized bleeding lesion in the small intestine, an intraoperative endoscopic examination could be a useful diagnostic method.

A Case of Acute Small Bowel Bleeding Diagnosed by Capsule Endoscopy / 대한소화기내시경학회지

Although small bowel is an uncommon origin of gastrointestinal bleeding, it is a predominant source of obscure gastrointestinal bleeding. Endoscopy is a mainstay of diagnosis and treatment of gastrointestinal bleeding, but small bowel is beyond the reach of the standard upper endoscopy and colonoscopy. Recently wireless capsule endoscopy has been known as a useful method in the diagnosis of small bowel bleeding. A 51-year-old man was admitted with acute abdominal pain and hematochezia. In spite of the conventional endoscopic and radiologic investigations, the bleeding source was not identified. Finally, wireless capsule endoscopy demonstrated drug induced enteropathy as a cause of small bowel bleeding. We report a case of drug induced small bowel bleeding diagnosed by capsule endoscopy with a review of the relevant literature.

A Case of Small Bowel Polyp Bleeding Diagnosed by Capsule Endoscopy / 대한소화기내시경학회지

Small bowel diseases are uncommon and difficult to be diagnosed by conventional methods such as endoscopy and radiologic study. Recently, wireless capsule endoscopy has been known as a new diagnostic method to detect the small bowel diseases, especially in patients with obscure gastrointestinal bleeding. A 48-year-old male patient admitted our hospital with signs of gastrointestinal bleeding and iron deficiency anemia. There was no evidence of bleeding in upper and lower endoscopic exams. Finally, wireless capsule endoscopy demonstrated small bowel polyp as a cause of obscure gastrointestinal bleeding. We report a case of small bowel polyp bleeding diagnosed by wireless capsule endoscopy with a review of relevant literatures.

A Case of Amyloidosis Presenting with Massive Small Bowel Bleeding / 대한소화기내시경학회지

The gastrointestinal (GI) tract is one of the commonly affected organs in amyloidosis. However, it is difficult to make a correct diagnosis of GI amyloidosis because of its varied clinical manifestation and nonspecific endoscopic findings. Moreover, GI bleeding as a presenting symptom is rare, but can be serious in some cases. Therefore, missed diagnosis and delayed management in GI amyloidosis may potentially lead to a critical outcome. We report a 51-year-old man with multiple myeloma whose major symptom was massive hematochezia due to GI amyloidosis. In our case, amyloid deposits could be distinctly visualized endoscopically in the stomach and the colon. They were manifested as submucosal hematomas in the small bowel resulting in massive bleeding that was successfully controlled with the aid of intraoperative endoscopy.

A Case of NSAID Induced Small Bowel Ulcer Bleeding Diagnosed by Capsule Endoscopy / 대한소화기내시경학회지

The small intestine has always been a problematic segments for endoscopic exploration in patients with obscure gastrointestinal bleeding. Recent emergence of capsule endoscopy has entailed a relevant diagnostic imaging advance for gastrointestinal conditions. Capsule endoscope can be used to detect small bowel bleeding. Some studies report that capsule endoscopy has the high diagnostic yield and is superior to enteroscopy and other diagnostic methods. We report here the first case of small bowel bleeding detected by using capsule endoscope in Korea, in a woman with hematochezia and a history of aspirin ingestion.

Comparative study of double-balloon enteroscopy and capsule endoscopy in etiological diagnosis of small intestine bleeding / 中华消化杂志

Objective To evaluate the diagnostic yield and accuracy of double balloon enteroscopy and capsule endoscopy in patients with obscure small bowel hemorrhage. Methods Twenty four patients with obscure small bowel hemorrhage were performed double balloon enteroscopy and wireless capsule endoscopy separately. The route of enteroscopy could be underwent either via mouth or via anus. Negative result of initial route was required afterwards for another via mouth or via anus examination. Capsule endoscope produced by GIVEN Imaging Company was used. The results of both methods were analyzed independently and final diagnosis of each case was compared thereafter. Results Totally 21 of 24 (87.5%) patients had positive findings with enterosocpy, while 11 of 24 (45.8%) patients had positive findings with capsule endoscopy. The etiological diagnosis of enteroscopy in all cases was confirmed by surgical exploration and pathological examination with the accuracy of 87.5% , however, the accuracy of capsule endoscopy was only 25% (6 cases). On assessment of procedure tolerance, double balloon enteroscopy under anaesthesia and capsule endoscopy were well tolerated than via mouth or anus route enteroscopy without anaesthesia. There was no severe procedure related complications. Conclusions The entire small intestine could be examined by double balloon enteroscopy with combination of mouth and anus route. Double balloon enteroscopy was superior to capsule endoscopy in etiological diagnosis of obscure small bowel bleeding. Capsule endoscopy had clinical diagnostic value in detection of multiple and long segment small bowel lesions. Double balloon enteroscopy could be served as the first option in diagnosis of obscure small bowel bleeding.