Extracolonic findings with the PillCam Colon: is panendoscopy with capsule endoscopy closer?

Background and study aims: Colon capsules display images from the moment they are ingested, making the study of other extracolonic areas possible. The aim of this study was to analyze the significance of these extracolonic findings. Patients and methods: In this single-center, prospective study, 165 patients underwent colon capsule endoscopy (CCE) between September 2009 and October 2012 to rule out colonic pathology. Images were recorded, without interruptions, from the moment the capsule was ingested until its battery ran out. The study was deemed complete when the capsule had traveled from the esophagus to excretion or until the hemorrhoidal plexus was observed. Results: CCE was used for colorectal cancer (CRC) screening (81.2 %), to investigate for chronic diarrhea (9.7 %) and chronic iron deficiency anemia (6.1 %), and for patients with incomplete colonoscopy (3.0 %). The capsule returned findings in the esophagus in 52.1 % of patients, in the stomach in 45.5 % of patients, and in the small bowel in 70.7 % of patients, with the findings being considered relevant in 4.9 %, 9.7 %, and 22.6 % of patients, respectively. The whole extent of the digestive tract was fully recorded in 86.1 % of patients and the Z line could be fully observed in 57.6 % of patients. There were no adverse events. Conclusions: CCE allows the recording of images from almost the whole extent of the digestive tract in most patients, enabling relevant pathologies to be identified in extracolonic areas, particularly the small bowel. Technical and procedural improvements are still necessary in order to achieve better observation of the stomach and esophagus.

Colon capsule endoscopy is a safe and useful tool to assess disease parameters in patients with ulcerative colitis.

OBJECTIVE: Colon capsule endoscopy (CCE) is a new endoscopic technique that is minimally invasive and allows evaluation of the colon mucosa without pain, sedation, and gas insufflation. To date, few studies have investigated the use of CCE in patients with ulcerative colitis (UC). This study compares the ability of CCE and a conventional colonoscopy to assess mucosal disease activity and the extent of inflammatory mucosa in patients with UC. METHODS: Forty-two patients (27 men, mean age 48.5 years) with known UC and indication for colonoscopy were enrolled in this single-blind, prospective study. All patients underwent CCE, followed by a colonoscopy. The activity and extent of the disease was assessed using Mayo scores and Montreal scores, respectively. RESULTS: There was a good correlation between CCE and colonoscopy in disease severity (κ=0.79; 95% confidence interval: 0.62-0.96) and extent of inflammation (κ=0.71; 95% confidence interval: 0.52-0.90) observed. The ability of CCE to assess a broad segment of distal ileum led to a change in the diagnosis of UC to ileocolonic Crohn's disease in three patients. Bowel preparation was considered adequate in 80% of the patients and no serious adverse events related to the CCE procedure or bowel preparation were reported. CONCLUSION: CCE is a safe and useful method for the evaluation of patients with UC. The ability of CCE to assess distal ileum provides an advantage to colonoscopy as CCE can identify patients who have been incorrectly diagnosed with UC, resulting in a change in their diagnosis to Crohn's disease.

Capsule endoscopy in patients refusing conventional endoscopy.

Capsule endoscopy is nowadays the diagnostic technique of choice in the study of small bowel pathologies, allowing the non-invasive study of the entire mucosa. This has led, together with new technical advances, to the creation of two new models (PillCam ESO and PillCam Colon) for the study of esophageal and colonic diseases. These two new capsules offer an interesting alternative to conventional endoscopy in the study of the upper and lower digestive tracts, because traditional endoscopy is often unpleasant and uncomfortable for the patient, can be painful, often requires moderate or deep sedation and is not without complications (hemorrhage, perforation, etc.). PillCam Colon is particularly important for its usefulness in the diagnosis of colonic polyps, and is a potentially useful tool in cases of incomplete colonoscopy or in colorectal cancer screening, even more when most patients are reluctant to undergo screening programs due to the said disadvantages of conventional colonoscopy. This article discusses the advantages of capsule endoscopy over conventional endoscopy, its current application possibilities and indications in routine clinical practice. In the various sections of the work, we assess the application of endoscopic capsule in different sections of the digestive tract (esophagus, stomach, and colon) and finally the potential role of panendoscopy with PillCam Colon.

EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos).

BACKGROUND: Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative. OBJECTIVES: To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability. DESIGN: Retrospective analysis of a prospectively maintained database. SETTING: Multicenter study, tertiary referral centers. PATIENTS AND INTERVENTIONS: Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment. RESULTS: There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 [57.9%]; ECA, 1/11 [9.1%]; P < .01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding. LIMITATIONS: Nonrandomized; EUS expertise necessary. CONCLUSIONS: EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data.

Eficacia de adalimumab en pacientes con enfermedad de Crohn y fracaso previo a la terapia con infliximab: resultados de una serie clínica / Efficacy of adalimumab in patients with Crohn's disease and failure to infliximab therapy: a clinical series

Introducción: adalimumab, un anti-TNF humano, ha demostrado ser efectivo en la inducción y tratamiento de mantenimiento de la enfermedad de Crohn moderada-grave. Existe menos experiencia, pero este fármaco parece también eficaz en los pacientes con pérdida de respuesta o intolerancia al infliximab. Objetivo: evaluar la eficacia de adalimumab durante un año, en nuestra serie de pacientes con enfermedad de Crohn (EC) y fracaso en el tratamiento previo con infliximab. Métodos: se incluyen 25 pacientes con enfermedad de Crohn y fracaso previo a la terapia con infliximab, que son tratados con adalimumab. Se utilizaron dosis de inducción de 160/80 mg en 24 pacientes y dosis de 80/40 en un paciente. Analizamos la respuesta clínica al tratamiento con adalimumab mediante el Índice de actividad de la enfermedad de Crohn (CDAI) y las concentraciones plasmáticas de proteína C reactiva (PCR), el cese de la corticoterapia y el cierre completo de las fistulas en la semana 48. Resultados: dieciocho de veinticinco pacientes (72%) alcanzan la remisión clínica (CDAI < 150) en la semana 24 y 15/25 pacientes (60%) en la semana 48. Esto se acompañó de un descenso de los niveles de PCR de 21 a 8 mg/l en la semana 48. En nueve de quince pacientes (60%) que tomaban corticoides, se consiguió su retirada. Tres de once pacientes (27%) con enfermedad fistulosa presentaron un cierre completo de las fístulas tras el tratamiento con adalimumab. Un 72% de los pacientes (18/25) necesitaron, a lo largo del seguimiento, acortar el intervalo de tratamiento a una semana para mantener la respuesta. Cinco de veinticinco pacientes (20%) presentan efectos secundarios y en 2 de ellos (8%) fue precisa la retirada del fármaco (meningitis tuberculosa y absceso abdominal). Conclusiones: el tratamiento con adalimumab proporciona una mejoría clínica y analítica en un número significativo de pacientes con EC y fracaso previo a la terapia con infliximab(AU)

Background: adalimumab, a human anti-TNF, is an effective induction and maintenance therapy for patients with moderate to severe Crohn’s disease. It seems to be effective in patients with resistance to infliximab, too, though the experience is more limited. Aim: to evaluate the efficacy of adalimumab, in patients with Crohn’s disease (CD) and failure to previous treatment with infli - ximab. Methods: twenty-five patients with CD and failure to previous treatment with infliximab were enrolled; they were treated with 160/80 (24 patients) and 80/40 (1 patient) induction doses. We analyze clinical response to treatment with adalimumab by the Crohn’s disease Activity Index (CDAI) and plasma concentration of C-reactive protein (CRP), steroid sparing and complete fistula closure at week 48. Results: eighteen out of twenty-five patients (72%) achieved clinical remission (CDAI score < 150) at week 24 and 15/25 (60%) patients at week 48. There was a statistically significant difference (p < 0.01) in CRP serum levels from 21 to 8 mg/dl at week 48. Nine out of fifteen patients (60%) treated with corticosteroids were able to discontinue steroids. Three out of eleven patients (27%) with fistulizing Crohn’s disease had complete fistula closure after the treatment. Seventy two percent of the patients (18/25) needed to increase adalimumab to weekly dose, in order to maintain clinical response. Five out of twenty-five patients (20%) had adverse events; two of them (8%) with serious adverse events (tuberculous meningitis and abdominal abscess) that forced the withdrawal of treatment. Conclusions: according to these data, adalimumab provides a clinical and analytical improvement in patients with CD and failure to previous therapy with infliximab(AU)

Patency and Agile capsules.

Small bowel strictures can be missed by current diagnostic methods. The Patency capsule is a new non-endoscopic dissolvable capsule which has as an objective of checking the patency of digestive tract, in a non-invasive manner. The available clinical trials have demonstrated that the Patency capsule is a good tool for assessment of the functional patency of the small bowel, and it allows identification of those patients who can safely undergo a capsule endoscopy, despite clinical and radiographic evidence of small-bowel obstruction. Some cases of intestinal occlusion have been reported with the Patency capsule, four of them needed surgery. So, a new capsule with two timer plugs (Agile capsule) has been recently developed in order to minimize the risk of occlusion. This new device stars its dissolution process earlier (30 h after ingestion) and its two timer plugs have been designed to begin the disintegration even when the device is blocked in a tight stricture.

Esophageal capsule endoscopy in patients refusing conventional endoscopy for the study of suspected esophageal pathology.

AIM: Esophageal capsule endoscopy is a well tolerated procedure that does not require sedation and has proved its value for the study of the esophagus. The aim of our study was to assess the feasibility, accuracy, safety and acceptability of esophageal capsule endoscopy for the study of gastroesophageal reflux disease and esophageal varices in patients who refused conventional upper gastrointestinal endoscopy. PATIENTS AND METHODS: Thirty consecutive examinations performed in 28 patients (15 men/13 women; mean age: 58.5+/-12.4 years; range: 23-87 years) were reviewed. Twenty-five examinations were performed in 23 patients presenting with chronic gastroesophageal reflux disease symptoms and the remaining five were carried out in patients with cirrhosis for screening of esophageal varices. The procedures were done with the new PillCam ESO that harbors two viewing cupules and takes a total of 14 frames/s. Technical data (total recording time, esophageal transit time and Z-line visualization), clinical findings (Savary-Miller grade; presence and characteristics of esophageal varices or portal hypertension gastropathy), and patient's opinion (quality and comfort questionnaire) were analyzed. RESULTS: All the patients ingested and excreted the capsule without complications. Two examinations in the gastroesophageal reflux disease group were repeated; one was issued as a follow-up and the other because no images were recorded in the first capsule endoscopy. From the former, only the satisfaction questionnaire was analyzed. Mean total recording time and esophageal transit time were 1224 and 243.79 s, respectively (range: 2-1192 s). Complete study of the Z-line was possible in 23 examinations (23/29; 79.3%). Esophageal erosions were seen in 58.33% (14/24) of the examinations carried out in patients with gastroesophageal reflux disease. Nine out of 14 patients (64.29%) presented with grade I esophagitis and the other five (35.71%) with grade II esophagitis. Among the five patients with cirrhosis, small varices were visualized in one (1/5; 20%), while large varices with red spots were evidenced in the remaining three (3/5; 60%). All four patients showing esophageal varices were found to have portal hypertension gastropathy. In most examinations, patients found the capsule easy to swallow (28/30; 93.33%), asymptomatic (29/30; 96.66%), evaluated the procedure as comfortable (29/30; 96.66%), and would repeat it if necessary (30/30; 100%). CONCLUSIONS: Esophageal capsule endoscopy is an adequate alternative diagnostic method for the study of gastroesophageal reflux disease and for the screening of esophageal varices in patients refusing to undergo conventional upper gastrointestinal endoscopy.