Maryland Capsule Conference Overview.ppt


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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
  • Maryland Capsule Conference Overview.ppt

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