Clinical utility of wireless motility capsule in patients with suspected multiregional gastrointestinal dysmotility.

BACKGROUND: Patients with gastrointestinal (GI) dysmotility often experience overlapping upper and lower GI symptoms suggestive of multiregional involvement. Wireless motility capsule (WMC) provides a full GI tract transit profile and may be able to detect and diagnose multiregional dysmotility. AIM: To determine the clinical utility and diagnostic yield of WMC in patients with upper and lower GI symptoms suggestive of multiregional GI dysmotility. METHODS: Retrospective chart review of all patients who had undergone WMC testing for suspected multiregional GI dysmotility from January 2009 to December 2012 at our institution was performed. Information regarding demographics, symptoms, medication use, prior diagnostic studies, and results of WMC testing was collected. RESULTS: A total of 161 patients were included in the analysis. Mean age was 43 ± 15 years, and 83 % were female. WMC was abnormal in 109 (67.7 %) subjects. Of these, 17 (15.6 %) patients had isolated delayed gastric emptying, 13 (11.9 %) patients had isolated delayed small bowel transit, and 25 (22.9 %) patients had isolated delayed large bowel transit. Multiregional dysmotility was diagnosed in 54 (49.5 %) patients. There was no significant difference in past medical or past surgical history between patients with isolated regional versus multiregional involvement. The presence or absence of various patient-reported symptoms by history did not predict an abnormal WMC study. CONCLUSIONS: Patients' symptoms are poor predictors of GI dysmotility and its anatomical extent. WMC can be a useful diagnostic test in these patients as it provides a comprehensive evaluation of the motility profile of the entire GI tract and provides objective evidence of multiregional involvement.

Diagnostic and therapeutic yield is not influenced by the timing of small-bowel enteroscopy: morning versus afternoon.

BACKGROUND: Small-bowel enteroscopies (BEs) are tedious and prolonged, and their efficacy may be affected by the timing of procedures. OBJECTIVE: We aimed to evaluate the differences in diagnostic yield, insertion depth, procedure duration, therapeutic yield, and adverse events (AEs) of enteroscopies performed in the morning versus the afternoon. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Patients who underwent BE for suspected small-bowel disease at a single institution between January 2008 and August 2009. MAIN OUTCOME MEASUREMENT: Differences in diagnostic yield, insertion depth, procedure duration, therapeutic yield, and AEs between morning (started before noon) and afternoon (after noon) procedures. RESULTS: A total of 250 enteroscopies were performed on 250 patients, of which 125 patients (50%) underwent a procedure in the morning and 125 patients (50%) underwent the procedure in the afternoon. The diagnostic yield with anterograde enteroscopy was the same in both the morning and afternoon (63.7% and 63.7%, respectively; P = .99). The procedure durations were also similar (42.4 ± 21.5 minutes vs 46.2 ± 22.4 minutes, respectively; P = .25). Similarly the diagnostic yield with retrograde enteroscopy was similar in morning and afternoon (44.1% and 35.3%, respectively; P = .46). However, the procedure durations of retrograde BE were significantly shorter in the morning compared with the afternoon (51.3 ± 21.3 minutes vs 66.6 ± 32.9 minutes, respectively; P = .03). Therapeutic yield and AEs were similar. LIMITATIONS: Retrospective study. CONCLUSIONS: The timing of procedure, morning versus afternoon, did not affect the diagnostic and therapeutic efficacy of BE in patients with suspected small-bowel disease.

Capsule endoscopy in examination of esophagus for lesions after radiofrequency catheter ablation: a potential tool to select patients with increased risk of complications.

BACKGROUND: Esophageal injury can result from left atrial radiofrequency ablation (RFA) therapy, with added concern because of its possible relationship to the development of atrial-esophageal (A-E) fistulas. OBJECTIVE: Evaluate utility of esophageal capsule endoscopy to detect esophageal lesions as a complication of RFA therapy in the treatment of atrial fibrillation (AF). METHODS: Consecutive patients with AF who underwent left atrial RFA therapy and received capsule endoscopy within 48 hours postablation. Video was reviewed by a single gastroenterologist. The medical records were also reviewed for symptoms immediately postablation and at the 3-month follow-up. RESULTS: A total of 93 consecutive patients were included and 88 completed the study and were analyzed. The prevalence of esophageal lesions was 17% (15/88 patients). Nine percent (8/88) of these patients had lesions anatomically consistent with the location of the ablation catheter. Six patients with positive capsule findings had symptoms of chest pain (3/6, 50%), throat pain (2/6, 33%), nausea (1/6, 17%), and abdominal pain (1/6, 17%). An additional 24 patients were symptomatic postablation, but with normal capsule findings. All patients with identified lesions by capsule endoscopy received oral proton pump inhibitor therapy, and were instructed to contact the Cleveland Clinic in the event of worsening symptoms. No delayed complications were reported at the 3-month follow-up. CONCLUSION: This study supports the use of capsule endoscopy as a tool for the detection of esophageal injury post-RFA therapy. PillCam ESO is well tolerated and provides satisfactory images of the areas of interest in the esophagus without potential risk related to insufflation with regular esophagogastroduodenoscopy.

Histological abnormalities of the small bowel mucosa in cirrhosis and portal hypertension.

AIM: To study the small bowel (SB) mucosa on biopsy in cirrhotic patients with portal hypertension and in non-cirrhotic controls and grade findings according to the Marsh criteria. METHODS: We prospectively enrolled 51 consecutive patients undergoing an upper endoscopy for their routine medical care. Twenty five patients with cirrhosis and portal hypertension were compared to 26 controls. We obtained coeliac serology and multiple upper small bowel biopsies on all 51 patients. A GI pathologist interpreted biopsies and graded findings according to the Marsh criteria. We assessed equivalence in Marsh grade between cirrhotic and non-cirrhotic controls using the Mann-Whitney test for equivalence. RESULTS: Gender, ethnicity and age were similar between both groups. Marsh grades were equivalent between the groups. Grade of 0 was present in 96% and grade of 1 was present in 4% of both groups and there was no villus atrophy or decrease in villus/crypt ratio in patients with portal hypertension. CONCLUSION: This study provides evidence for the lack of villus atrophy in patients with cirrhosis and portal hypertension, and supports the continuous reliance on the Marsh criteria when the diagnosis of coeliac disease is to be made in the presence of cirrhosis.

The utility of capsule endoscopy small bowel surveillance in patients with polyposis.

BACKGROUND: Small intestinal (SI) surveillance is recommended for polyposis patients. The utility and safety of capsule endoscopy (CE) for surveillance of SI neoplasia in patients with familial adenomatous polyposis (FAP) and Peutz-Jeghers syndrome (PJS) is unknown. METHODS: CE was offered to consecutive FAP and PJS patients due for routine upper endoscopic surveillance. The prevalence, location (jejunum, ileum), size (1-5 mm, 6-10 mm, >10 mm) and number (1-5, 6-12, >20) of polyps detected by CE was assessed. RESULTS: 19 subjects (15 FAP/4 PJS) with a mean age of 43 were included. All subjects had previous intestinal surgery. No complications occurred with CE. CE in FAP: 9/15 (60%) of subjects with FAP had SI polyps. The prevalence of SI polyps was related to the duodenal polyposis stage and subject age. The location, size and number of polyps progressed as duodenal polyposis stage advanced. CE in PJS: 3/4 (75%) of subjects with PJS had SI polyps. The polyps were diffuse in 2/4 and only in the ileum in one subject. CE findings led to laparotomy with intra-operative endoscopic polypectomy in two PJS patients. CONCLUSION: SI polyps are common in FAP but their importance is unknown. CE should be performed in FAP patients with stage III and IV duodenal disease. Clinically significant polyps are commonly detected by CE in PJS and lead to change in management in 50% of PJS subjects. CE should replace radiographic SI surveillance for PJS patients. CE is safe in polyposis patients who have undergone major intestinal surgery.

Video capsule endoscopy: a voyage beyond the end of the scope.

Video capsule endoscopy (VCE), an important innovation in diagnostic endoscopy, was approved in 2001 and is now widely available. In this system, the patient swallows a miniature high-resolution camera that is propelled by peristalsis through the gastrointestinal tract. It is particularly useful in examining the small intestine, which is difficult to visualize by conventional endoscopic techniques.

The accuracy of an endoscopy nurse in interpreting capsule endoscopy.

OBJECTIVE: The average physician time required to view a wireless capsule endoscopy study at our institution is 50 min. It is unknown whether a nurse could preview the capsule endoscopy video and accurately detect all significant lesions. If so, it may allow the physician to review only the predetected abnormalities and thereby greatly reduce physician reading time. Our aim was to evaluate whether a nurse can accurately detect lesions on capsule endoscopy. METHODS: An endoscopy nurse who was trained to read capsule endoscopy reviewed 20 consecutive capsule endoscopy studies and recorded all findings. The same studies were viewed independently by a gastroenterologist. The two sets of recorded findings were reviewed, and a comparison of the accuracy in detecting landmarks and clinically significant lesions was made. RESULTS: The nurse missed two of 27 significant lesions seen by the gastroenterologist (93% sensitivity, 95% CI = 74-99%), and the gastroenterologist missed three seen by the nurse. The nurse accurately recorded gastric emptying time and time of passage through the ileocecal valve to within 1 min of the times recorded by the gastroenterologist in 18 of 20 patients (90% agreement, 95% CI = 67-98%). CONCLUSIONS: In this study, the endoscopy nurse detected 93% of the clinically significant lesions seen by the gastroenterologist. The clinical implication of this is that a physician extender could preread capsule endoscopies, allowing the gastroenterologist to view only the demarcated abnormalities. This could improve the cost effectiveness of capsule endoscopy and lead to wider physician acceptance of the test.