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  • Enteroclysis may be more accurate but requires a skilled radiologist, light sedation because it is uncomfortable, and much more expensive.
  • pE can find a cause in 30-50% of cases
  • Wear loose clothing; Avoid airports/malls
  • Stricture may be missed on small bowel ft Plain films can be obtained
  • Have a phone nearby: Radio is nice. Cup of coffee and popcorn!
  • Obscure GI bleeding represents 2-10% of GI bleeds-ranges from iron def anemia to g+ stool to overt bleeding Initial experience with capsule shows that it may reveal a source of bleeding in about 50% of such patients

Transcript

  • 1. Wireless Capsule Endoscopy Eric Goldberg, M.D. Assistant Professor of Medicine University of Maryland Medical Center April 8th, 2006
  • 2. Case Presentation
    • SN is a 74 year old male with coronary artery disease, and chronically anticoagulated with coumadin for a artifical aortic valve, who presented 6 months prior to admission with melena and a hematocrit of 22%.
    • Upper endoscopy and colonoscopy were normal at that time. He was transfused, started on iron therapy and discharged home.
    • He was readmitted 2 months later with similar symptoms and a hematocrit of 18%. Repeat EGD and colonoscopy were again normal. An enteroscopy was performed to the proximal jejunum and was normal. He was again transfused, and discharged home.
  • 3. Case Presentation
    • SN was readmitted again, 1 month prior to admission.
    • EGD : normal.
    • Small bowel follow through exam : normal.
    • Tagged RBC scan : normal.
    • Angiogram : Interventional radiology declined
    • Intra-operative enteroscopy . Surgery declined: Risks> Benefits
    • The patient was admitted a fourth time. He had received a total of 18 units of red blood cells over the preceding 6 months.
  • 4.  
  • 5.  
  • 6. S.N. Diagnosis: Bleeding AVM in Mid Jejunum
  • 7. Enteroscopy: Bleeding in Mid-Jejunum
  • 8. AVM in Mid Jejunum
  • 9. AVM Post- Argon Plasma Coagulation
  • 10. Follow Up
    • SN has remained transfusion free for 12 months. He no longer takes iron and continues his coumadin therapy for his artificial aortic valve.
  • 11. Patient
    • XX is a 32 year old female with a history of Crohn’s disease for ten years. Eight years ago, she underwent a terminal ileal resection with an ileo-transverse colon anastomosis.
    • For the past 6 months, she was experiencing 4-6 loose stools per day and mid abdominal pain. She denied obstructive symptoms such as nausea, vomiting or obstipation.
    • She was being treated with pentasa 3 grams/d and enterocort
    • Laboratory evaluation was significant for an ESR of 55
    • A SBFT was normal
    • A colonoscopy was normal to the terminal ileum
  • 12.  
  • 13. Case Presentation
    • TR is a 69 year old male with recurrent melena. The patient initially presented 12 months earlier with melena and a HCT of 18%. An EGD and colonoscopy were normal. A small bowel follow through examination was negative. The patient was transfused, started on iron therapy and discharged.
    • He presented this admission with symptomatic anemia (HCT 14%) and OB+ stool. A repeat colonoscopy was negative. An enteroscopy was normal 30cm past the ligament of Treitz.
    • A capsule endoscopy was ordered…
  • 14.  
  • 15.  
  • 16.  
  • 17.  
  • 18. Small Bowel Follow Through
  • 19. Evaluation of the Small Intestine
    • Push Enteroscopy
    • 2.5meter long push enteroscopy
    • Sonde and rope-way enteroscopy
    • Angiography
    • Red cell scans
    • Intra-operative enteroscopy
    • Double Balloon Enteroscopy
  • 20.  
  • 21. History
    • Early 1980’s: Dr Gavriel Iddan, an Israeli mechanical engineer began working on electro-optical imaging devices for missiles.
    • 1981: Dr Iddan goes on sabbatical in Boston- meets Dr Eitan Scapa, a gastroenterologist.
    • The idea of developing a miniature missile that could pass through the GI tract and record images was born.
    • 1994: Dr Paul Swain presents the possibility of wireless capsule endoscopy in an invited talk entitled Microwaves in Gastroenterology at the LA World Congress of Gastroenterology
  • 22. History
    • 1995-1996: Dr Swain develops several prototype wireless capsule endoscopy systems
    • 1996: First live transmission from a pig
    • 1997: US patent
    • 1998: New start-up company: GIVEN imaging: G astro I ntestinal V ideo EN doscopy
    • 2000: Animal trials presented at DDW
    • August, 2001: FDA approval
    • 2004: Esophageal Capsule Endoscopy
    • Future…
  • 23. The Capsule
    • Diameter 11mm: Length 26mm
    • Optical dome: Intestinal illumination by white light emitting diodes (LED’s)
    • Lens
    • Complementary metal-oxide silicone imager (color camera chip)
    • Transmitter
    • Two batteries (silver oxide)
  • 24. Features of the Capsule
    • Capsule takes two images per second
    • On average, 50,000 images are obtained during an 8 hour exam
    • Magnification: 8x
    • Capsule coating: non-adherant
    • Disposable
  • 25. “ Physiologic Endoscopy”
    • Bowel is visualized in its normal state
      • No “scope trauma”
      • Air insufflation not a factor
    • Exam can be performed on anticoagulation
  • 26.  
  • 27. GE Junction Duodenum Jejunum Ileocecal Valve
  • 28. Phlebectasia AVM Lymphangectasia Bleeding Lesion
  • 29. Lymphoma GIST Polypoid Mass Polyp
  • 30. NSAID stricture Radiation Enteritis Sprue Villous Drop Out
  • 31. Performance
    • Overnight 12 hour fast
    • Sensors placed on patient
    • Patient wears a belt that contains a data recorder.
    • Patient ingests capsule around 8am
    • Patient may have clears two hours after ingestion
    • Patient may have a light lunch 4 hours after ingestion
    • Avoid other patients who ingested a capsule.
    • Patient returns 7-8 hours later
  • 32. Average Transit Times
    • Stomach : One hour
    • Small Intestine : 4 hours
    • Capsule Passage : 2-3 days
  • 33. Complications
    • Retention of capsule: 1-5%
    • Bowel obstruction: .5 %
    • Aspiration: Rare
  • 34. Contraindications
    • Absolute :
    • Suspected small intestinal obstruction
    • Pacemakers/AICD’s.
    • Pregnancy
    • Relative :
    • Motility disturbances: Gastroparesis/Achalasia
    • Small bowel diverticulosis
    • Poor surgical candidates
  • 35. Informed Consent
    • WCE does not replace examination of the stomach or colon
    • Risk includes bowel obstruction that may require surgery
    • No MRI’s until capsule has passed
    • May not visualize the entire small bowel
  • 36. Reading the Study
    • Reading times can vary from 20 minutes to 2 hours
    • Can read up to 25 frames/sec in single frame mode. I recommend 12-15 frames/second
    • Gadgets to speed reading times
      • Red finding software
      • Double/Quadruple frame imaging
      • Quick view
  • 37. Capsule Endoscopy: Changing the Practice of Gastroenterology
    • Obscure gastrointestinal bleeding
    • Evaluation of extent of small intestinal disorders such as Crohn’s disease or Celiac sprue
    • Abnormal small intestinal imaging
    • Surveillance of polyposis syndromes involving small intestine