Double-balloon endoscopy for small intestinal disease: a single-center experience in Hungary.

BACKGROUND: We report on our experience with the Fujinon EN-450 T5 therapeutic double-balloon endoscope (DBE) and compare our findings with the results of earlier capsule endoscopy. MATERIAL/METHODS: Between August 2005 and July 2009, 150 DBE procedures were conducted in 139 consecutive patients (M/F: 67/72, age: 51.1 years, SD: 18.6 years) who presented at our tertiary referral hospital. The results of previous capsule endoscopy (CE) examinations were available in 27 patients. The indications for DBE included obscure gastrointestinal bleeding (OGIB) in 83 patients, suspected/known IBD in 25, and polyposis/suspected neoplasia in 29 patients. All of the examinations were performed at our outpatient clinic. RESULTS: In OGIB, abnormal small-bowel findings were noted in 50 patients (60.2%) including angiodysplasias, erosions, and small ulcers. Malignancy was found in 6 patients (7.2%), while an intervention was carried out in 24 patients. In suspected IBD cases, IBD was diagnosed in 5/13 cases. In known IBD patients, assessment of the extent as well as disease behavior and activity was the indication. In polyposis/suspected malignancy, polyps were removed by snare polypectomy in 8 Peutz-Jeghers patients, while primary adenocarcinoma was diagnosed in 4. The concordance of CE and DBE findings was 51.8% (14/27), while in 2 cases DBE provided significantly new information, including 1 malignancy. The average insertion length was app. 213 cm (range: 70-480 cm). CONCLUSIONS: Based on our experience, DBE is a safe and useful method for evaluating and treating small-bowel disease in selected patients with obscure bleeding, IBD or polyposis syndromes. The concordance of DBE and CE in this real-life setting was only fair.

Small bowel alterations in portal hypertension: a capsule endoscopic study.

BACKGROUND/AIMS: The endoscopic appearance in portal hypertension is well described in the stomach and the colon, but there is a limited number of data available on small bowel changes. The present retrospective, comparative study was aimed to analyse the diagnostic yield and describe the small bowel findings with capsule endoscopy in cirrhotic patients with gastrointestinal bleeding of unknown origin. METHODOLOGY: Capsule endoscopy findings of 11 cirrhotic patients with portal hypertension and 22 non-cirrhotic patients with gastrointestinal bleeding who had undergone non-diagnostic upper endoscopy and colonoscopy, which were then compared. RESULTS: In total, 9A and 2B cirrhotic patients were examined based on Child-Pugh score with a mean age of 66.2 (+/- 7.6) years. Lesions originated to portal hypertension were found in all cirrhotic patients, most frequently multiple angiodysplasias (63.6%), while in the control group multiple angiodysplasias were a seldom finding (18.2%). None of the radiological and endoscopic examinations of the small bowel before capsule endoscopy showed positive findings in cirrhotic patients. CONCLUSION: Capsule endoscopy is an effective diagnostic method with high diagnostic yield in portal hypertension. Multiple angiodysplasias are the most probable findings as the source of small bowel bleeding in these patients.

[Small intestine capsule endoscopy in the diagnostics of coeliac disease]. / A vékonybél kapszulás endoszkópos vizsgálata. A coeliakia diagnosztikája.

Coeliac disease is an autoimmune enteropathy precipitated by the gluten content of cereals. It had for long been considered a childhood condition as clinical symptoms manifested when gluten was introduced into the diet. The introduction of specific serological markers changed our understanding of the epidemiology and semiology of the syndrome. The main difficulty of the diagnostics arises from the fact that over 50% of patients with gluten-sensitive enteropathy show atypical symptoms, while coeliac-disease patients with extra-gastrointestinal manifestations show no gastrointestinal symptoms at all. Diagnostics of coeliac disease is currently based on the detection of specific antibodies and the histological assessment of the duodenum. Macroscopic signs of villous atrophy (reduction in the number or loss of Kerking's folds, vascular pattern visible through the mucosa, "mosaic or micronodular" pattern, "scalloped" folds) are clearly visible in untreated patients. Capsule endoscopy, contrary to conventional endoscopic approaches, enables non-invasive, pain-free investigation of the entire small intestine. Duodenal mucosa is visualised at an 8:1 magnification during the investigation, enabling the assessment of villous atrophy by an experienced investigator. Based on preliminary experience, standard upper tract endoscopy and capsule endoscopy appear to exhibit equal levels of sensitivity and specificity for coeliac disease. The advantage of CE versus upper tract endoscopy lies in the complete assessibility of the small intestine, thus also enabling the assessment of the spread and severity of the disease. The disadvantage associated with the approach is the lack of histological biopsy samples. CE is recommendable as a first line approach for patients with proven coeliac disease when alarm conditions appear.

[Capsule endoscopy for the diagnostics of small intestine tumours]. / A kapszulás endoszkópia jelentosége a vékonybéltumorok diagnosztikájában.

Three to six percent of all gastrointestinal tumours and one to two percent of all malignant gastrointestinal tumours develop in the small intestine. These occur more frequently in men than in women and the peak of occurrence is at the age of 50 to 60 years. According to epidemiological investigations to date the most frequently developing primary tumours in the small intestine are adenocarcinomas, carcinoid tumours, lymphomas and small bowel gastrointestinal stromal tumours. Clinical appearance of the tumours is the same, independent of their histological type. Fifty percent of the benign tumours is asymptomatic and is only discovered incidentally at autopsy. In comparison, 80% of malignant tumours is symptomatic. The prognosis of small intestine malignant tumours is very poor as at the time of diagnosis they have already formed metastases in 45-75% and at the time of surgery they are in 20-50% irresectable. The reason for the late diagnosis is on the one hand the non-specific nature of the symptoms, on the other hand, the limited visualisation of the entire small intestine via traditional radiological and endoscopic methods. Capsule endoscopy (CE) revolutionised the diagnostics of the small intestine by enabling non-invasive, pain-free investigation of the entire small intestine. The timely application of CE may replace a range of expensive assays with limited diagnostic value. Initial results indicate a higher prevalence of small intestine tumours than it had been estimated based on earlier epidemiological investigations. The new method provides an early diagnosis, enabling a definitive therapy, eventually significantly improving patient survival.

[The role of capsule endoscopy in the diagnosis of small bowel Crohn's disease]. / A kapszulás endoszkópia szerepe a vékonybél Crohn-betegségének diagnosztikájában.

Historically, there have been several modalities available for diagnosing small bowel diseases, but - until recently - endoscopic examination of this part of the gastrointestinal tract was not possible. With its direct visualization of bowel mucosa, the 2002 premier of capsule endoscopy was a major break-through in gastroenterology. The most important indication of small bowel capsule endoscopy is Crohn's disease, it provides valuable diagnostic information in patients with suspected, proven and post-operative disease, too. Several clinical studies proved CE's superiority over other methods. Although young age was a contraindication initially, numerous studies have proved its safety and efficacy in pediatric patients. Complications of CE are rare, the main risk is capsule retention and consequent small bowel ileus which can be prevented by a previous trial examination with a digestible, biodegradable patency test-capsule.

[Small bowel stromal tumors diagnosed by capsule endoscopy]. / Vékonybél-stromatumorok diagnózisa kapszulás endoszkópiával.

UNLABELLED: Small intestinal stromal tumors account for approximately 35% of all gastrointestinal stromal tumors. Gastrointestinal bleeding is considered as one of the main clinical symptoms for SISTs. Capsule endoscopy has brought revolution in small bowel diagnostics, as it is considered the best method of visualisation of the entire small intestine. Besides, it is well tolerated by patients and is accompanied by a low number of complications. It is also indicated as the first diagnostic method in gastrointestinal bleeding of obscure origin, following negative upper endoscopy and colonoscopy. CASE REPORT: 2 patients (a male and a female, aged 58 and 69, respectively) presented with obscure gastrointestinal bleeding have been examined by capsule endoscopy after negative upper endoscopy and colonoscopy. Videorecords have been assessed in both cases by two independent experts. The capsule reached the Bauchin-valve in both cases during the 8 hours of the testing time and the entire small bowel was clearly visible. - Based on the capsule endoscopic images, for one of the two cases a tumor has been reported as the background of the small intestinal bleeding. In the other case we could mark the location of the bleeding, while we were unable to ascertain the type of the actively bleeding lesion during the test. In order to determine the accurate bleeding source double-balloon enteroscopy was performed in the second case. After surgery the histological and immunohistochemical tests have justified the presence of spindle cell GISTs. Taking into consideration the Fletcher-classification, for the tumor size and the mitotic index, both cases can be classified as a GIST of low malignant potential. CONCLUSIONS: An early diagnosis and application of a definitive therapy become possible by using capsule endoscopy, therefore the chance of survival of the patients might be increased.

[Screening and surveillance for hereditary polyposis and non-polyposis syndromes with capsule endoscopy]. / Hereditaer intestinalis polyposis- és nem polyposisos szindrómák követése és szurése kapszulás endoszkópiával.

The hereditary polyposis syndromes and non-polyposis colorectal carcinoma have been considered as scarcely occurring but inheritable dominant autosomal syndromes. The increasing risk of small bowel carcinoma and prevention of obstruction and intussusception have been making frequent and acute surgical interventions unavoidably led to the necessity of screening and surveillance the patients. Earlier the diagnosis of these symptoms was difficult to establish because traditional radiological methods have a low yield for small polyps. Furthermore, small bowel is only partially accessible with traditional endoscopic techniques such as upper endoscopy, colonoscopy and push-enteroscopy. The "wireless" capsule endoscopy has opened the way then for the non-invasive and painless test of the entire small intestine. - Test results have been cumulated to justify the efficiency and safety of capsule endoscopy concerning the syndromes above. This method can be applied safely even consequently to repeatedly performed surgical interventions by low risk of capsule retention. As the results compared of the diagnosed familial adenomatous polyposis and of Peutz-Jeghers syndrome reflect on capsule endoscopy, its diagnostic sensitiveness is stated as significantly higher than the Barium-contrast X-Ray and MR-enterography. Nevertheless, determination of size and location of polyps has become more problematic when evaluating the test results.

[Multiple angiodysplasias diagnosed by capsule endoscopy]. / Multiplex angiodysplasiák diagnózisa kapszulás endoszkópiával.

UNLABELLED: Angiodysplasias are the most frequent vascular lesions of the gastrointestinal tract and sources of significant mortality from bleeding. Small bowel angiodysplasias account for approximately 40% of cases of gastrointestinal bleeding with obscure origin and represent the single most common cause for hemorrhage in this subset of patients. Their cause is unknown but most are probably acquired and the result of a degenerative process associated with aging. The difficulty of their diagnosis stems from their multiple appearance and small size. Examinations that have been performed so far support that the sensitivity of capsule endoscopy (CE) performed during active bleeding was higher than in case of previous overt bleeding and occult bleeding. CASE REPORT: A 61-year-old female patient, who has received anticoagulant therapy for 13 years, presented with recurrent gastrointestinal bleeding of obscure origin underwent wireless capsule endoscopy after negative upper endoscopy and colonoscopy. CE showed non-bleeding typical angiodysplasia in the antrum of the stomach and active bleeding in the first third of jejunum without a visible bleeding source. As the next diagnostic step we performed selective mesenteric angiography to clarify the diagnosis and at the same time we also applied radiological intervention. CONCLUSION: Capsule endoscopy changed in practice guidelines for obscure bleeding and became the first-line method for evaluation of patient after upper endoscopy and colonoscopy have been shown to be negative. If the examination is performed early, CE could shorten considerably the time to diagnosis, lead to definitive treatment and numerous examinations with low yield could be avoided. The therapy of small bowel angiodysplasias is questionable. Radiological intervention poses the least load for the patient.

[Role of capsule endoscopy in patients with portal hypertension and obscure gastrointestinal bleeding]. / Kapszulás endoszkópia szerepe portalis hypertensióban tisztázatlan eredetû gastrointestinalis vérzés esetén.

BACKGROUND AND AIMS: Limited number of data are available on small bowel changes due to portal hypertension. The present retrospective, comparative study was aimed to analyse the diagnostic yield and to describe the findings with capsule endoscopy of cirrhotic patients with obscure gastrointestinal bleeding. PATIENTS AND METHODS: Capsule endoscopy findings of 11 cirrhotic patients with portal hypertension and 22 non-cirrhotic patients with gastrointestinal bleeding who had undergone non-diagnostic upper endoscopy and colonoscopy were compared. Capsule video recordings were evaluated by two investigators at both workplaces. Patients after capsule endoscopy were followed-up until a mean of 19 (1-42) months. RESULTS: In total 7 men and 5 women were examined at two medical centres in 48 months with a mean age of 66.2 (+/-7.6) years. The average period between the first clinical symptoms and capsule endoscopy was 15.7 (+/-14.9) months. During this period patients were hospitalized in an average of 2.8 (+/-1.3) times and 7.9 examinations were performed per patients prior to capsule endoscopy. A small bowel bleeding source was diagnosed in all 11 patients. Two definitive bleeding sources were observed in 7 patients (63%). Lesions connected to portal hypertension were found in all patients (8 angiodysplasias, 2 portal hypertensive enteropathies and 1 bowel varix). During the follow-up period rebleeding occurred in 27.3% of cirrhotic patients compared with 18.2% rebleeding rate in the control group. CONCLUSION: Capsule endoscopy is a useful method in patients with portal hypertension and obscure gastrointestinal bleeding after negative upper endoscopy and colonoscopy. Multiple angiodysplasias are often diagnosed in the background of small bowel bleedings, and several bleeding sources frequently occur in these patients.

[Evaluation of diagnostic yield and clinical impact of capsule endoscopy in patients with obscure gastrointestinal bleeding]. / A kapszulás endoszkópia diagnosztikus értékének és klinikai kihatásának vizsgálata tisztázatlan eredetu gasztrointesztinális vérzésekben.

BACKGROUND AND AIMS: The major indication of small bowel capsule endoscopy is the diagnostics of obscure gastrointestinal bleeding. The present retrospective study was aimed to analyze the diagnostic yield, positive and negative predictive values and clinical impact of capsule endoscopy in patients with obscure gastrointestinal bleeding. PATIENTS AND METHODS: During a 36 month period at two workplaces 66 capsule endoscopy studies were performed in 62 patients with gastrointestinal bleeding who had undergone non-diagnostic upper endoscopy and colonoscopy. Capsule video recordings were evaluated by two investigators at both workplaces. Capsule endoscopy findings were divided into 3 groups according to the bleeding source: definitive bleeding source (48 patients), uncertain bleeding potential (5 patients), and negative finding (8 patient). Patients after capsule endoscopy were followed-up until a mean of 20 (1-41) months. RESULTS: A definitive small bowel bleeding source was detected in 78.7% of the cases studied by capsule endoscopy. Definitive bleeding sources included angiodysplasia (28 cases), small bowel Crohn's disease (5 cases), small bowel tumor (5 cases), small bowel stenosis (2 cases), NSAID therapy related ulcer (1 case), non-specific inflammation (1 case) and helminthiasis (1 case) respectively. The positive and negative predictive values of capsule endoscopy studies were 95.8% and 84.6% respectively. In cases with definitive bleeding sources 72% of patients received therapy in accordance with capsule endoscopy findings (surgery in 18 patients, medical treatment modification in 16 patients, chemoembolisation in 1 patient). During the follow-up period 17.7% of the patients had rebleeding. CONCLUSIONS: Capsule endoscopy is a useful and effective diagnostic method in cases with obscure gastrointestinal bleeding. Effective therapy may be introduced in accordance with the majority of positive capsule endoscopy results.

[Gastrointestinal stromal tumors (GISTs): clinical and pathological features]. / Gastrointestinalis stroma tumorok (GISTs): klinikai és patológiai jellemzok.

Gastrointestinal stromal tumors (GISTs): clinical and pathological features. The gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. With immunohistochemical, electron microscope and molecular examinations they can be clearly distinguished in both their genotype and phenotype from other mesenchymal tumors. GIST tumors express the CD 117 receptor in more than 90% independent of histopathological features and clinical behaviour. This is why it is considered as the most important characteristic. The incidence is 10-20 new cases per 1 million annually. The number of incidents is expected to increase by the establishment of CD117 and other new markers (protein kinase C theta, DOG1). Nowadays the establishment of the expected biological behavior and malignancy can be difficult. The best prognostic factors are the tumor size and the mitotic index. Dominantly, due to the mutation of the c-kit proto-oncogene and PGDFRA gene that the high level tyrosine kinase activity generates resulting uncontrolled proliferation and cell growth. The imatinib mesylate is a selective inhibitor of the KIT tyrosine kinase receptor and it also blocks the activity of the PDGFRA kinase. The therapeutic consequence of this is that the majority of advanced GIST tumors which do not react to conventional radio- and chemotherapy respond well to tyrosine kinase inhibitor treatment. As a result, survival and patient's quality of life can significantly improve.