The Usefulness of Capsule Endoscopy

Transcription

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

2 Obscure Gastrointestinal Bleeding

3 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):

4 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

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6 6 138 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

7 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:

8 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 Elsevier Inc:71-90

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

10 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

11 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

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

13 Case # 1 Small bowel capsule endoscopy performed.

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

18 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

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

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21 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

22 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

23 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

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

25 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

26 Capsule Endoscopy Findings Video

27 Capsule Endoscopy Findings Video

28 Capsule Endoscopy Findings

29 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

30 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

31 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

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

33 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

34 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

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

36 Case 3: Capsule Endoscopy Findings Video

37 Case 3: Capsule Endoscopy Findings

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39 Meckel s Diverticulum Occur in the distal ileum, 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:

40 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

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

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

43 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

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

45 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

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

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

50 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

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

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

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54 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

55 Case # 5 EGD report from earlier in the year from Italy negative (translated) Colonoscopy report with ileal intubation negative for overt pathology (translated) Next Step?

56 Audience Question What is the next step in this patient s management? a) Repeat EGD/colonoscopy b) Capsule endoscopy c) Celiac serologies d) Hemoglobin electrophoresis

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58 Audience Question What is the next step in this patient s management? a) Repeat EGD b) Empiric gluten free diet c) Celiac serologies d) Hemoglobin electrophoresis

59 Case # 5 Celiac serologies negative Low serum IgA level Refused HLA haplotyping due to cost NEXT STEP?

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63 Diagnosis Upon further questioning... Multiple family members with epistaxis and anemia Diagnosis: HHT Gluten enteropathy

64 HHT Autosomal dominant disorder Telangiectasias which are small arteriovenous shunts involving dilated arterioles and venules Typical presentation: Recurrent nosebleeds beginning in adolescence/early adulthood Chronic GI blood loss Symptoms related to visceral AVMs including pulmonary, hepatic, cerebral and spinal

65 Curaçao Diagnostic Criteria Epistaxis: spontaneous, recurrent nosebleeds Telangiectasias: multiple at characteristic sites (lips, oral cavity, fingers, nose) Visceral lesions: GI telangectasias (with or without bleeding) or arteriovenous malformations (pulmonary, hepatic, cerebral, spinal) Family history: a first-degree relative with HHT

66 Curaçao Diagnostic Criteria

67 HHT - Treatment Therapies include: Aggressive iron supplementation Endoscopic ablation Estrogen/progesterone Somatostatin/octreotide Thalidomide Patient placed on gluten free diet and underwent DBE with APC ablation. Remains on iron therapy.

68 QUESTIONS?