Capsule endoscopy: are we making the most of all its benefits?

Abstract

Since small-bowel (SB) endoscopic exploration beyond Treitz's angle (usually the farthest point reached by upper digestive endoscopy (UDE) with a gastroscope) was introduced, upper digestive tract (UDT) lesions overlooked by UDE were reported, diagnosed "de novo" initially by oral push enteroscopy (OPE) (2), and subsequently by small-bowel capsule endoscopy (SBCE) (3) and then double-balloon enteroscopy (DBE). All these endoscopic explorations went through segments already examined by prior UDEs that had yielded negative results even when performed by the same clinician. Why is this?In this issue Benito Velayos and colleagues (4) study this, and report their retrospective UDT findings following diagnosis with SBCE after a single negative UDE procedure. They specifically refer to obscure gastrointestinal bleeding (OGIB). In a substantial 17% of patients the authors diagnosed UDT conditions significant enough to indicate a second UDE, with a high impact on patient management changes.Consistency in so-called "stable" mucosal lesions such as polyps is easier with endoscopy as compared to changing conditions such as digestive bleeding, where the time factor has proven critical for diagnostic effectiveness. In the natural history of hemorrhage CE may document initial bleeding findings (often not revealing the underlying cause, made invisible by blood itself), the responsible lesion, or finally a scarred or healed lesion with no pathological findings whatsoever. The dominant lesion, the true origin of bleeding, must be differentiated from simple findings. Angiodysplasia, the "princeps" lesion in OGIB, may also be a clinically non-significant finding, particularly if small in size and no bleeding is seen to originate in it. This is probably the case with the finding by the authors of gastro-duodenal angiodysplasia using SBCE in a patient where an initial UDE provided no diagnosis and a second UDE procedure finally found gastric cancer.Our concern is intrinsically complex when the lesion also is vascular in nature -despite attempts at nomenclature standardization for these lesions, a single endoscopic exam may provide various diagnostic interpretations regarding characterization, whereas a second exploration, even by the same clinician, may set the record straight.OGIB has been recently defined by the 2007 world consensus meeting in Berlin (5) as any gastrointestinal bleeding event whose cause remains unknown after UDE and colonoscopy with ileoscopy. Bleeding should be located in the SB if its origin in the UDT and colon was effectively excluded, which has given rise to a new emerging concept: mid gastrointestinal bleeding (MGIB) (6), with particular characteristics versus the traditional lower gastrointestinal bleeding (LGIB) beyond Treitz's angle. In MGIB the origin of bleeding lies within the SB, between the papilla of Vater and Bahuin's valve, and this condition has a special behavior regarding severity, transfusional requirements, stays, and overall cost, even if it only represents Capsule endoscopy -are we making t...

Intestinal obstruction secondary to endoscopic capsule retention

“…Endoscopic capsule (EC) allows images to be obtained of the small bowel mucosa. The main indication is the study of the gastrointestinal bleeding of obscure origin (1). Capsule retention is uncommon, for which reason we present a case that developed intestinal obstruction after capsule ingestion.…”