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THE SMALL BOWEL VIDEO CAPSULE ENDOSCOPY — TEN YEARS EXPERIENCE IN LATVIA
Rodina J.1- 2, Derovs A.1-2, Derova J.2- 4, Pokrotnieks J.2- 3
1 Riga East Clinical University Hospital, Riga, Latvia
2 Riga Stradins University, Riga, Latvia
3 Pauls Stradins Clinical University Hospital, Riga, Latvia
4 Latvian Maritime Medicine Center, Riga, Latvia
КАПСУЛЬНАЯ ЭНДОСКОПИЯ ТОНКОЙ КИШКИ: 10 ЛЕТНИЙ ОПЫТ В ЛАТВИИ *
Родина Е.1- 2, Деровс А.1-2, Дерова Е.2 4, Покротниекс Ю.2 3
1 Рижская Восточная клиническая университетская больница, Рига, Латвия
2 Рижский Университет им. Страдыня, Рига, Латвия
3 Клиническая Университетская больница им. П. Страдыня, Рига, Латвия
4 Латвийский Центр Морской Медицины, Рига, Латвия
* Иллюстрации к статье на цветной вклейке в журнал
Rodina J. Gastroenterology, hepatology and nutrition clinic at Riga East clinical university hospital; MD
Derovs A. Head of Gastroenterology, hepatology and nutrition clinic at. Riga Stradins University, Department of Internal
Diseases; MD, PhD, assistant professor
Derova J. Head of Gastroklinika at Latvian Maritime Medicine Centre. Riga Stradins University, Department of Internal Diseases; MD, assistant
Pokrotnieks J. Head of Gastroenterology, hepatology and nutrition centre at Pauls Stradins clinical university hospital. Riga Stradins University, Department of Internal Diseases; MD, PhD, professor
Родина Е. Врач-резидент-гастроэнтеролог Рижской Восточной клинической университетской больницы; доктор медицины Деровс А. Заведующий клиникой Гастроэнтерологии, гепатологии и клинического питания Рижской Восточной клинической университетской больницы. Кафедра Внутренних болезней Рижского Университета им. П. Страдыня; д.м.н., доцент Дерова Е. Заведующая Гастроклиникой Латвийского Центра Морской Медицины. Кафедра Внутренних болезней Рижского Университета им. П. Страдыня; доктор медицины, ассистент
Покротниекс Ю. Заведующий центром Гастроэнтерологии, гепатологии и клинического питания Клинической университетской больницы им. П. Страдыня. Кафедра Внутренних болезней Рижского Университета им. П. Страдыня; д.м.н., профессор
Derovs Aleksejs
Деровс Алексейс aleksejs.derovs@ gastroenterologs.lv
Summary
Introduction. Video capsule endoscopy (VCE) is relatively new, informative and minimally invasive endoscopic diagnostic method for assessment of the small bowel mucosa.
Objective. To evaluate the clinical significance of ten years' experience of VCE in Latvia.
Materials and methods. A retrospective review of patients who underwent VCE between July 2006 and July 2016 was conducted. All patients had undergone previous negative endoscopic examinations before VCE. Special original study protocol with more than 370 parameters was fulfilled for each patient. All the data was entered into the database with consecutive statistical analysis using SPSS ver.19.
Results. In total out of 530 VCE were performed, due to technical reasons 421 patients' data were entered into the database. Out of these, 245 (58,2%) patients were females and 176 (41,8%) — males. Patients' age was varied from 13 to 82 (mean 44.39 ± 16.36) years. VCE most common indications were: Crohn's disease (26.1%), unclear iron deficiency anemia (22.8%), chronic unexplained abdominal pain (20.4%) and obscure bleeding from the digestive tract (17.1%). VCE findings were justified as clinically significant in 255 (60.57%) of cases. In 152 (36.10%) — findings were doubtful, and in 14 (3.33%) — clinically insignificant. Bowel preparation prior to capsule endoscopy was performed using one of the four schemes. Bowel cleanliness was statistically significantly better (p = 0.03) using 2 liters or 4 liters of polyethylene glycol-based electrolyte
solution. Regional transit abnormalities (RTA) in 55 (13.1%) cases. Positive statistically significant correlation was observed between presence of RTA without changes / defects in the small bowel mucosa and patients age (p = 0.028).
Conclusions:
1. VCE is clinically significant examination in patients with Crohn's disease, obscure bleeding from the digestive tract, unexplained anemia and chronic unexplained abdominal pain, which also allows changing the patient's further treatment tactics.
2. 2 liters and 4 liters of polyethylene glycol-based electrolyte solution are by far the most efficient bowel preparation schemes prior VCE.
3. RTA is more common in the elderly patients.
Keywords: Video capsule endoscopy (VCE), small bowel, VCE indications, bowel preparation prior VCE, regional transit abnormalities.
Eksperimental'naya i Klinicheskaya Gastroenterologiya 2016; 135 (11): 39-47
Резюме
Введение. Видео капсульная эндоскопия (ВКЭ) является относительно новым, информативным и малоинвазивным эндоскопическим методом диагностики, которое позволяет обследовать слизистую оболочку тонкого кишечника.
Цель работы. Клиническая оценка 10 летнего опыта ВКЭ в Латвии.
Материалы и методы. Ретроспективный анализ данных ВКЭ, которая была проведена в двух Латвийских больницах на протяжении десяти лет. Для каждого пациента был заполнен специальный оригинальный протокол исследования с более чем 370 параметрами. Все данные были введены в базу данных с последующим статистическим анализом в программе SPSS ver.19.
Результаты. В общей сложности было проведено 530 ВКЭ. По техническим причинам в базу были занесены данные о 421 пациенте. Из них 245 (58.2%) пациентов были женщины и 176 (41.8%) — мужчины. Возраст пациентов варьировал от 13 до 82 (в среднем 44.39 ± 16.36) лет. Наиболее распространенные индикации для проведения обследования были: болезнь Крона (26.1%), железодефицитная анемия неясного генеза (22.8%), хронические необъяснимые боли в животе (20.4%) и кровотечения из желудочно-кишечного тракта неясной локализации (17.1%). Находки ВКЭ были клинически значимыми для 255 (60.57%) пациентов, значимость находки была спорна в 152 (36.10%) и клинически незначительна в 14 (3.33%) случаях. Подготовка кишечника перед капсульной эндоскопией была выполнена по одной из четырех схем. Была выявлена положительная статистически значимая корреляция между схемами подготовки тонкого кишечника и уровнем чистоты слизистой оболочки (р = 0.03). Используя схемы с 2 или 4 литрами раствора полиэтиленгликоля очистка кишечника была значительно лучше. Региональные нарушения транзита наблюдались в 55 (13.1%) случаев. Положительная статистически значимая корреляция наблюдалась между наличием нарушений регионального транзита капсулы в участках кишечника без визуальных изменений / дефектов в слизистой оболочке и возрастом пациентов (р = 0.028).
Выводы:
1. ВКЭ является клинически значимым обследованием и позволяет изменять дальнейшую тактику лечения пациентам с болезнью Крона, кровотечением из желудочно-кишечного тракта неясной локализации, железодефицитной анемией неясного генеза и хроническими болями в животе неясного генеза.
2. На сегодняшний день схемы с использованием 2 или 4 литров раствора полиетиленгликоля являются наиболее эффективными схемами подготовки кишечника перед ВКЭ.
3. Нарушения регионального транзита капсулы в участках кишечника без визуальных изменений в слизистой оболочке чаще встречается у пожилых пациентов.
Экспериментальная и клиническая гастроэнтерология 2016; 135 (11): 39-47
Introduction
Similarly, to all other areas of medicine, there is a continuous growth in the area of gastroenterology. In the last couple of decades, there have been thrilling achievements in the fields of gastroenterological disease screening, diagnostics, and treatment. The video capsule endoscopy (VCE) is a fundamentally new method in diagnostic endoscopy, which was gradually introduced to the clinical practice starting from 2001. VCE is completely different from all other conventional endoscopic methods in that it is a passive, little invasive, well-tolerated method and it fills an information gap in cases where the other methods are insufficient. The goal of using this method is diagnosing pathologies of the small bowel (SB). The diagnostic modalities used until now for examining this part of gastrointestinal system are both very troublesome for the patient and technically difficult for the operator (conventional enteroscopy) or are uninformative (radiologic studies with contrast). [1]
VCE is a wireless one-time-use capsule device which is swallowed and moves through the gastrointestinal tract due to intestinal motility, during which digital pictures are taken. [1, 2, 3, 4, 5]
In accordance with the European Society of Gastrointestinal Endoscopy (ESGE) latest 2015 year guidelines VCE has following indications:
• Unexplained gastrointestinal bleeding;
• Iron deficiency anemia;
• Crohn's disease (CD);
• Tumors of the small intestine;
• Hereditary polyposis syndrome;
• Celiac disease. [1]
Other controversial indications as non-steroid antiinflammatory drug (NSAID) associated small intestine damage, unexplained abdominal pain, etc., which were included in the ESGE2006 year guidelines, were removed from the last version. [3]
In general, VCE is safe and well tolerated examination for patients with a very low risk of complications. However, as any examination, it also has some contraindications:
• Patients with a high risk of capsule retention;
• Pregnant women;
• Patients with severely impaired gastrointestinal passage;
• Patients who have swallowing difficulties, because the capsule endoscope may accidentally get into the trachea. [2, 3, 8, 22]
The aim of work was to analyze retrospective data of VCE, which is carried out in Latvia during the period from July 2006 to June 2016, and to evaluate the clinical significance of the examination.
Materials and Methods
Study design and patients
This is a multicenter retrospective study. Ten-year data of VCE examinations were collected. VCE examinations were made in two Latvian hospitals (Paul's Strains clinical university hospital and Latvian Maritime Medical center) during the period from July 2006 to June 2016. Indications and contraindications for examination were established in accordance with the ESGE Guidelines.
Specially designed original questionnaire with different parameters was fulfilled for each patient. It
VCE procedure
We have used three capsule endoscopy systems: Olympus endocapsule, Given Imaging PillCam and OMOM Capsule Endoscope equipped with standard software applications for these systems. Pictures were taken at a rate of 2 fps.
All patients underwent a bowel preparation that consisted of transparent fluid intake (at will) 24 hours prior to examinations, and one of the following schemes: 1) ingestion of 2 liters of Polyethylene glycol-based electrolyte solution (2lPEG); ingestion of 4 liters polyethylene glycol day before the investigation (4lPEG); 3) ingestion of 30ml of castor oil day before the investigation (Cas)
Quality assessment
Two independent interpreters performed the analysis of each patient's VCE recording. The internationally recognized definitions and criteria were used for
included the following characteristics: referrals data, demographic data, VCE indications, medical history and physical examination data, patient preparation method prior VCE, previous laboratory and instrumental examination results, VCE data etc.
Prior to VCE examination, all patients have undergone the upper and/or lower endoscopy, as well as various radiologic studies (including angiography, CT, MRI, irigoscopy, intestinal transit studies) with no significant pathology established.
and 4) 24 hours of fasting prior VCE (Fas). The main scheme was 2lPEG or Cas. The alternative of ingesting 4 liters of polyethylene glycol was chosen for cases where delayed transit time was suspected. Fasting for 24 hours was used for patients with contraindications for polyethylene glycol.
The assessment of the intestinal cleanliness according to the utilized by us scale was as follows: excellent (no bubbles, no fluid in the lumen); satisfactory (bubbles and fluid are partly hindering visualization of the SB mucosa); poor (due to the bubbles and fluid solitary areas of the SB mucosa cannot be visualized).
interpretation. The research was carried out in accordance with the Helsinki Declaration.
Result interpretation
According to VCE finding patients were divided into three groups: patients with a clinically significant, doubtful and clinically insignificant finding. The distribution was based on the fact, how much the examination findings influence future treatment tactics. The first group included chronic diseases such as Crohn's disease and celiac disease, findings, that often requiring radical medical intervention as tumors of the small intestine or important changes in treatment tactics as erosive enteropathy, angiodysplasia, NSAID enteropathy, ulcerative-erosive enteropathy, parasites in small intestine and protein-losing enteropathy.
Group with doubtful findings included conditions, which are not clearly connected with patients complains, but could initiate changes in a treatment plan. Here we aggregated pathologies such as segmental enteropathy, GI polyposis and multiple hemangiomas. The third group included pathologies, which could not affect the patient complains and further treatment. These conditions were justified as clinically insignificant and consisted of diverticular disease, multiple uplifts of small bowel mucosa, solitary polyps in small bowel, multiple flebectasia and multiple lymphangiectasia.
Results
Overall, during the period from July 2006 to June 2016 530 VCE were performed. Due to technical reasons, 421 examinations data were entered in database. Out of these, 245 (58.2%) patients were women, and 176 (41.8%) — men.
The age of patients ranged from 13 to 82 (44.39 ± ± 16.36) years. Thirteen cases examination was carried out in pediatric patients aged 13 to 17 years (mean 15.38 ± 1.45 years). Distribution of patients by age decades is summarized in Table. 1:
According the study protocol VCE referrals were as follows:
• Unexplained anemia 96 (22.8%) pts.;
• Unexplained gastrointestinal bleeding 72 (17.1%) pts.;
• Coeliac disease, proven or suspected 15 (3.6%) pts.;
• Crohn's disease (CD), proven or suspected 110 (26.1%) pts.;
• Tumors of the small intestine 18 (4.3%) pts.;
• Chronic unexplained abdominal pain 86 (20.4%) pts.;
• Less common indications such as chronic diarrhea 8 (1.9%) pts. and chronic constipation 5 (1.2%) pts.;
• Parasites of the gastrointestinal tract 5 (1.2%) pts., suspected foreign body in the small intestine 2 (0.5%) pts. and suspected eosinophilic enteritis 1 (0.2%) pts.;
• Other indications 3 (0.7%).
Patients distribution by VCE referrals are summarized in Table 2.
Bowel preparation prior to VCE examination is summarized in Table 3:
Information about SB cleanliness assessment, depending on the SB preparation scheme o is summarized in Table 4:
Overall, excellent and satisfactory cleanliness of the small intestine was reached in majority of patients — 376 (89.3%). Statistically significant positive correlation between the patient preparation schemes and small intestine cleanliness was found (x2 = 13.949, p = 0.03), respectively, the best cleanliness was observed in patients with 2lPEG and 4lPEG schemes.
Capsule endoscopy time was highly variable from 309 to 631 (476.7 ± 42.7) minutes. Capsule retention in the stomach (a situation when the capsule was located there for more than 90 minutes), was noted in 42 (10.0%) patients. Capsule retention rate in stomach was not statistically significant affected neither by patient's age, neither by existing co-morbidities.
Regional transit abnormalities (RTA1 — when the capsule was located in the segment of the small bowel without visual defects of mucosa at least for 60 minutes, RTA2 — when the capsule at least for 60 minutes was located in the segment with visual defects of mucosa) was observed in 55 (13.1%) patients, RTA1 in 39 (9.3%), RTA2-17 (4%) cases. Statistically significant positive correlation between patient age and RTA1 was found (x2 =15.692, p = 0.028), respectively, the regional transit disorders in small intestine segment without visual defects of mucosa were more frequently observed in older patients.
VCE findings were summarized in Table 5. Additionally, see Fig. 1-8,
Considering the fact that most common referrals for VCE were: Crohn's disease, unexplained anemia, chronic unexplained abdominal pain and unexplained gastrointestinal bleeding, information about these indications and VCE finding were summarized separately as well. (Table 6-9).
Table 1.
Distribution of patients by age decades.
It should be noted that for 45 or 52.3% of patients with unexplained abdominal pain, VCE finding changed further treatment tactics.
Clinical significance of VCE findings were summarized in Table 10.
Capsule retention occurred in 4 patients, or 0.95% of cases. Three of these patients VCE resulted with Crohn's disease finding, one segmental enteropathy. Surgical treatment for evacuation of the capsule was used in one patient with segmental enteropathy diagnosis.
Table 2.
Distribution of patients by VCE referrals.
Patient's preparation scheme Patient number Patient number in%
Fas 25 5.9
21PEG 187 44.4
41PEG 86 20.4
Cas 123 29.2
Table 3.
Distribution of patients by intestinal preparation prior to VCE administration
Patient preparation The degree of bowel cleanliness
scheme excellent satisfactory poor
Fas 2 (8%) 17 (68%) 6 (24%)
21PEG 47 (25.1%) 129 (69.0%) 11 (5.9%)
41PEG 20 (23.3%) 56 (65.1%) 10 (11.6%)
Cas 23 (18.7%) 82 (66.7%) 18 (14.6%)
Table 4.
Small bowel mucosal cleanliness depending on the patient preparation scheme before VCE
Table 5.
VCE findings.
Table 6.
VCE findings for patients with indication — Crohn's disease (proven or suspicious), n=110.
Table 7.
VCE findings for patients with indication — unexplained anemia, n=96.
Table 8.
VCE findings for patients with indication — chronic unexplained abdominal pain, n=86.
Table 9.
VCE findings for patients with indication — unexplained bleeding from the digestive tract, n=72.
Table 10.
Clinical significance of VCE findings
Clinical significance of VCE findings
Clinically significant findings Doubtful clinical findings Clinically insignificant findings
• Erosive enteropathy (103; 24.47%) • Crohn's disease (76;18.05%) • Angiodysplasia (29; 6.89%) • Celiac disease (17; 4.04%) • Tumors in small intestine (11; 2.61) • NSAID enteropathy (10; 2.38%) • Ulcerative-erosive enteropathy (6; 1.43%) • Parasites in small intestine (2; 0.48%) • Protein-losing enteropathy (1; 0.28%) • Segmental enteropathy (149; 35.39%) • GI polyposis (2; 0.46%) • Multiple hemangiomas (1; 0.28%) • Diverticular disease (8; 1.9%) • Multiple uplifts of small bowel mucosa (2; 0.48%) • Solitary polyps in small bowel (2; 0.48%) • Multiple flebectasia (1; 0.28%) • Multiple lymphangiectasia (1; 0.28%)
255 (60.57%) 152 (36.10%) 14 (3.33%)
Discussion
421 of VCE examinations analyzed in the study is a relatively high number, comparable with similar studies, which are often based on approximately the similar or a smaller number of patients. Frietas et al. has described
the four years of experience in VCE, servicing data on 118 patients. [24] Kav et al. shared with data of five years ofexperience in capsule endoscopy, describing the data of 120 patients. [22] Mostly articles about VCE were based
on a single examination indication and its data collection. Most common indication specter in our study is similar with indications, described in literature.
The study demographic data were not significantly different from the literature data. Patients' distribution by gender was uniform (58.2 / 41.8%) and did not statistically affected the results ofthe study. The age of patients ranged from 13 to 82 years with an average age of 44.39 ± 16.36 years and normal age distribution curve. Pediatric patients were 13, which is not much. The average age of pediatric patients was 15.38 ± 1.45 years. Frequent indication ofVCE in these group was Crohn's disease (4 patients or 30.7%), obscure gastrointestinal bleeding (3 cases or 23.1%) and celiac disease (2 patients or 15.4%). There is quite a lot of data of VCE for pediatric patients in literature. VCE for patients from 10 to 18 years of age has been launched in 2004. In 2009 the Food and Drug Administration (FDA) has approved the examinations for patients in age from 2 years. In meta-analysis Oliva et al. has described the data on 995 pediatric patients undergoing VCE and age of the patients ranged from 1.5 to 18 years. In our study data about pediatric patients group is not wide and are limited with adolescents (13-17 years). [27, 29]
Originally the ESGE guidelines early version (2006) [3] was used to establish VCE indications. The guidelines were revised and expanded (2009, 2015) [1, 2] and, consequently, it also changed our study examination indication spectrum. For relatively large group of patients (86 patients or 20.4%) examination was carried out because of unexplained chronic abdominal pain that matched to earlier ESGE guidelines, but it was no longer mentioned in 2009 and 2015. Early (2006) ESGE guidelines described this indication as additionally possible. These were patients, who undergo radiological (irrigoscopy, colonography with barium, computed tomography) and endoscopic (upper and lower gastrointestinal (GI) endoscopy) examinations, but the cause of pain still was not found. There are number of studies in literature describing patients with VCE due to chronic abdominal pain. Egnatios et al. has studied efficacy of VCE in patients with chronic abdominal pain, assessing how much finding will influenced or changed the future treatment strategy. Data of 607 VCE were collected, of which 90 were carried out in connection with chronic abdominal pain. In general, clinically significant abnormalities were detected less frequently compared to patients for whom the examination was carried out because of other indications. As well as finding influenced or changed further treatment tactics lesser. Also frequency of VCE findings was higher in cases when with the exception of chronic abdominal pain, patients had accompanying symptoms, such as nausea, vomiting and weight loss. [17] The largest study in this area took place in China (Yang L. et al ). As similar to the previous one, VCE usefulness in patients with chronic abdominal pain was evaluated. The study included 243 patients. 19 patients (7.8%) were diagnosed with Crohn's disease, 15 (6.2%) with enteritis, 11 (4.5%) — idiopathic intestinal lymphangiectasia, other pathological findings included the small intestine tumors, ascariasis, uncinariasis and other. [18] Similar conclusions as in our study were made previously with the smaller number of patients (Derova et al., 2010), when VCE was found to be informative procedure in the cases of chronic unexplained abdominal pain and provided information about the possible causes ofpain in 66.67% of cases. [30] In our study, patients with chronic abdominal pain prevailed
segmental enteropathy (n = 38, 44.9%) erosive enteropathy (n = 31, 36.1%) and Crohn's disease (n = 7, 8.1%). In one case, parasite invasion was found in the small intestine and in one patient the tumor of small bowel was discovered. Consequently, in 52.3% of the cases findings of VCE significantly influenced subsequent patient treatment tactics. It was particularly important in patients with established erosive enteropathy, small intestine tumors and earlier not diagnosed Crohn's disease in the small intestine, which requires timely treatment and observation. However, this indication remains controversial worldwide.
One of the basic indications of VCE is Crohn's disease. Because of the possible disease localization in the whole digestive tract, starting from the mouth to the anus, VCE uses to determine the inflammatory process of the small intestine. In 30-40% of patients' disease affects the small intestine only (in up to 90% of the cases terminal ileum is affected), in 40-55% ofthe cases inflammatory process is localized in the small and large intestine. [31] Examination is also valuable in the cases of indeterminate colitis, where the disease is characterized by an abnormal finding in the small intestine. In these cases VCE helps to establish diagnosis ofCD. VCE are also used in assessment ofthe disease progression and treatment effectiveness evaluation. It is very important because even if the colon mucosal healing is reached, it is not always improving inflammatory process in the small intestine. [32] There are many studies available in literature that describe VCE higher efficiency in the small intestine pathological changes determination for CD patients compared to the other investigative techniques such as barium passage, computed tomography and magnetic resonance imaging. [12, 16, 32] Being that they allow detect only transmural inflammation, namely to assess the bowel wall, but don't particularly visualize the mucosa of the intestine. Consequently, in our study CD took a leading role among VCE indications, and was the basis for 110 (26.1%) examinations.
Second most frequent VCE indication in our study was unexplained anemia (96 or 22.8%). After Pennazio et al. VCE is indicated for patients with undetected bleeding reasons, when upper and lower GI endoscopy did not find the cause of anemia. In the situation, when other organ system pathology is excluded as a possible cause of anemia. [1] After Muhammad et al. this type of situation with the negative findings of upper and lower endoscopy has found in 20% of anemic patients. About a third part of these patients has detectable changes in the small intestine mucosa. [33] Consequently, VCE is recommended as firstline examination method in patients with iron deficiency anemia and pre-existing upper and lower endoscopy. [1, 11]
Obscure bleeding from digestive tract was indication for examination in 72 (17.1%) of cases. ESGE recommends VCE as a first-line metho d of investigation for patients with unexplained gastrointestinal tract bleeding. In patients with visible obscure GI bleeding it recommended as soon as possible, preferably within 14 days of first bleeding episodes in order to increase the efficiency of examination. VCE is minimally invasive compared with enteroscopy and more effective compared to other investigative techniques, such as barium radiography / enteroclysis, angiography and radioisotope examinations, which are less sensitive in the absence of strong profuse bleeding. [1, 2, 9, 10]
There are five VCE systems available in the word, from which three types of systems were employed in the study: Given Imaging Pill-Cam, Olympus Endo Capsule and
OMOM Capsule Endoscope. The choice of the system was not determinated by medical factors. Mostly in 352 or 83.6% of cases OMOM capsule was used. Statistically significant superiority of some VCE system is not described in the literature.
Patient preparation prior VCE examination was performed with four schemes, but only in 21.9% of cases the intestinal wall was visualized perfectly, showing that the patient's preparation schemes are not fully effective. Perfect intestine cleanliness more frequently was found in patients with 2lPEG and 4lPEG preparation schemes, satisfactory — 2lPEG scheme, in turn, poor bowel cleanliness was observed in cases with Fas scheme. Similarly, fasting scheme inferiority described Niv Y. et al, comparing fasting effectiveness with the use of 45 ml of sodium phosphate before the examination. A poor visualization was found in 35% of patients with Fas scheme and only in 4% of patients, using sodium phosphate. [19] Fas inferiority scheme is also described in the meta-analysis, which included eight studies with the total number of patients — 237, in which good visualization was found in 78% of cases, preparing the bowel before examination and only in 49% of cases without preparation. [20]
Regional transit abnormalities during VCE recording was observed in 55 (13.1%) cases. In a larger group of patients (39 or 9.3% of patients) it was not associated with visual defects in the small intestine mucosa (RTA1). Statistically significant positive correlation was found between patients' age and RTA1 (x2 = 15.692, p = 0.028), respectively, RTA1 occurred more frequently in elderly patients. In MEDLINE database, searching for key words: capsule endoscopy, transit time, transit abnormalities, age, was not found any studies that described the age association with VCE transit abnormalities. RTA2 or regional transit abnormalities that were associated with the intestinal mucosa defects were found in 17 (4%) patients. It was specific to younger age patients, compared with RTA1. In 11 of 17 cases with RTD Crohn's disease was found due to VCE. Consequently, this age tendency probably is associated with the gut wall transmural lesions that develops in CD and can lead to the development of serious complications as bowel stenosis with obstruction or fistula formation, and an early manifestation of the disease. There are no comparative studies of the capsule endoscope transit abnormalities risk in patients with CD, compared with other indication groups. However, there are higher capsule retention risks in CD patients, in comparison with patients with other pathologies. [3, 28] Most frequent VCE findings were segmental enteropa-thy, erosive enteropathy, Crohn's disease, angiodysplasia in the small intestine and celiac disease. More rarely tumors in the small intestine, diverticular disease and NSAIDs enteropathy were found. At suspicion of Crohn's disease, VCE confirmed the diagnosis of CD in 46.4% of cases, or 51 out of 110 patients with a given indication. It corresponds to the literature data, where CD is one of the most often
found abnormality due to VCE examination, in the same way as unexplained bleeding from the GI. According to our data most frequent causes of unexplained GI bleeding were erosive enteropathy (31.9%) and angiodysplasia (26.4%) in the small intestine. Kav et al. also described the erosions (25.8%) and angiodysplasia (12.5%) as the main causes of bleeding in the small intestine. [22] In patient group with VCE indication "unexplained anemia" most frequent findings were: segmental enteropathy (49%), erosive enteropathy (21.9%) and Crohn's disease (8.3%). According to Tong et al. VCE has a relatively low diagnostic value (25.7%) in patients with unexplained anemia, but our study showed that VCE significantly influenced the further treatment tactics in the higher proportion of patients (49%). [34] It could be related to thorough patient selection prior VCE.
According to Oliva et al. VCE indications and findings are different for adults and pediatric patients. In our study in the first group most frequent findings was segmental enteropathy (149 or 345.4% of the patients), erosive enteropathy (103 or 24.5%) and Crohn's disease (76 or 18.1%). By contrast, in greater number of pediatric patients — CD (5 or 38.5% of the patients) and celiac disease (4 or 30.8%) were found.
According to VCE finding we can divide patients into three groups: patients with a clinically significant, doubtful and clinically insignificant finding. There are no studies with similar type of classification in literature. But, presumably, careful analysis of this type of data may be helpful to assess the importance of examination in clinical practice and helps with patient's selection prior to VCE. In our study in 255 (60.57%) findings were clinically significant, findings was doubtful in 152 or 36.10% and clinically insignificant in 14 or 3.33% of cases. Important change in treatment tactics was needed in 255 or 60.57% of cases, the potential change or corrections in second group of patients in 152 or 36.10% ofcases. VCE findings influenced treatment strategy in more than 90% of all examinations, which points out that careful patients selection was performed prior VCE.
For the majority of patients (26.1%, or 110 patients) examination was conducted because ofproven or suspected Crohn's disease in the small intestine. Patients who are suspected to have a CD need to be assessed very carefully prior VCE. Because the disease is characterized by transmural bowel wall damage and development of stenosis, there is a risk of developing complications of the examination with the capsule transit disorders or retention. Due to Rey et al. this complication is described in 5% of patients with CD. [3] According to the research data, the risk of complications in patients with CD resembles to prior described. Capsule retention occurred in 3 of 76 CD patients or in 3.9% of cases. It also must be said that one patient was 15 years old. Overall, of 408 adult patients capsule retention occurred in 3 cases, but of the 13 children in 1 patient. As was mentioned above in three patients Crohn's disease was found, in turn, one VCE examination shoved segmental enteropathy and retention cause has not been established.
Conclusions
1. VCE is clinically significant examination in patients with Crohn's disease, obscure bleeding from the digestive tract, unexplained anemia and chronic unexplained abdominal pain, which also allows changing the patient's further treatment tactics.
2. 2lPEG and 4lPEG are by far the most efficient bowel preparation schemes prior VCE.
3. RTA1, when the capsule was located in the segment of the small bowel without visual defects ofmucosa at least for 60 minutes is more common in the elderly patients.
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К статье
The small bowel video capsule endoscopy — ten years experience in Latvia (p. 39-47) Капсульная эндоскопия тонкой кишки: 10 летний опыт в Латвии (стр. 39-47)
Fig. 1.
Erosive enteropathy (From Dr.med. A. Derovs records)
Fig. 2.
Crohn's disease
(From Dr.med. A. Derovs
records)
Fig. 3.
Ulcerose-erosive enteropathy (From Dr.med. A. Derovs records)
Fig. 4.
Angiodysplasia
(From Dr.med. A. Derovs
records)
»
Fig. 5.
Segmental enteropathy (From Dr.med. A. Derovs records)
Fig. 6.
Small bowel tumor (From Dr.med. A. Derovs records)
Fig. 7.
NSAID enteropathy (From Dr.med. A. Derovs records)
Fig. 8. GI polyposis
(From Dr.med. A. Derovs records)
