Long-term follow-up of patients undergoing capsule and double-balloon enteroscopy for identification and treatment of small-bowel vascular lesions: a prospective, multicenter study.

BACKGROUND AND STUDY AIMS: Few data are available concerning the long-term outcome of patients treated endoscopically for bleeding small-bowel vascular lesions (SBVL). The aim of this study was to evaluate the risk of rebleeding after endoscopic therapy for SBVLs detected by video capsule enteroscopy (VCE). The secondary aim was to assess risk factors for rebleeding. PATIENTS AND METHODS: A prospective, multicenter study (15 centers) was conducted, involving patients with obscure gastrointestinal bleeding and SBVL on VCE who were treated during double-balloon enteroscopy (DBE). The likelihood of bleeding was defined according to VCE findings, as high or low. RESULTS: A total of 183 patients underwent endotherapy during DBE, and 64 (35 %) had rebleeding during the 1 year follow-up period. Multivariate analysis indicated that cardiac disease (hazard ratio [HR] 2.04, 95 % confidence interval [CI] 1.20 - 3.48; P < 0.01) and the presence of overt bleeding (HR 1.78, 95 %CI 1.07 - 2.97; P = 0.03) at presentation were associated with the risk of rebleeding. The association between chronic renal failure and the risk of rebleeding was close to statistical significance (HR 1.77, 95 %CI 0.94 - 3.33; P = 0.08). Kaplan-Meier analysis suggested that patients treated during DBE for a lesion with low likelihood of bleeding on VCE had higher rebleeding rates than those with a high likelihood of bleeding (HR 1.87, 95 %CI 0.94 - 3.37; P = 0.07). CONCLUSION: Despite long-term remission in most patients, about one-third had rebleeding at 1 year. Independent risk factors for rebleeding were cardiac disease and overt bleeding at original presentation. The lesion characteristics on VCE may be useful to evaluate the bleeding potential of the lesion and may be used for better selection of patients for DBE.

Multicenter comparison of double-balloon enteroscopy and spiral enteroscopy.

BACKGROUND AND AIM: Spiral enteroscopy is a novel technique for small bowel exploration. The aim of this study is to compare double-balloon and spiral enteroscopy in patients with suspected small bowel lesions. METHODS: Patients with suspected small bowel lesion diagnosed by capsule endoscopy were prospectively included between September 2009 and December 2010 in five tertiary-care academic medical centers. RESULTS: After capsule endoscopy, 191 double-balloon enteroscopy and 50 spiral enteroscopies were performed. Indications were obscure gastrointestinal bleeding in 194 (80%) of cases. Lesions detected by capsule endoscopy were mainly angioectasia. Double-balloon and spiral enteroscopy resulted in finding one or more lesions in 70% and 75% of cases, respectively. The mean diagnosis procedure time and the average small bowel explored length during double-balloon and spiral enteroscopy were, respectively, 60 min (45-80) and 55 min (45-80) (P=0.74), and 200 cm (150-300) and 220 cm (200-300) (P=0.13). Treatment during double-balloon and spiral enteroscopy was possible in 66% and 70% of cases, respectively. There was no significant major procedure-related complication. CONCLUSION: Spiral enteroscopy appears as safe as double-balloon enteroscopy for small bowel exploration with a similar diagnostic and therapeutic yield. Comparison between the two procedures in terms of duration and length of small bowel explored is slightly in favor of spiral enteroscopy but not significantly.

Obscure gastrointestinal bleeding: preliminary comparison of 64-section CT enteroclysis with video capsule endoscopy.

OBJECTIVE: To retrospectively compare the diagnostic capabilities of 64-section CT enteroclysis with those of video capsule endoscopy (VCE) to elucidate the cause of obscure gastrointestinal bleeding. METHODS: Thirty-two patients who had 64-section CT enteroclysis and VCE because of obscure gastrointestinal bleeding were included. Imaging findings were compared with those obtained at double balloon endoscopy, surgery and histopathological analysis, which were used as a standard of reference. RESULTS: Concordant findings were found in 22 patients (22/32; 69%), including normal findings (n=13), tumours (n=7), lymphangiectasia (n=1) and inflammation (n=1), and discrepancies in 10 patients (10/32; 31%), including ulcers (n=3), angioectasias (n=2), tumours (n=2) and normal findings (n=3). No statistical difference in the proportions of abnormal findings between 64-section CT enteroclysis (11/32; 34%) and VCE (17/32, 53%) (P=0.207) was found. However, 64-section CT enteroclysis helped identify tumours not detected at VCE (n=2) and definitely excluded suspected tumours (n=3) because of bulges at VCE. Conversely, VCE showed ulcers (n=3) and angioectasias (n=2) which were not visible at 64-section CT enteroclysis. CONCLUSION: Our results suggest that 64-section CT enteroclysis and VCE have similar overall diagnostic yields in patients with obscure gastrointestinal bleeding. However, the two techniques are complementary in this specific population.

Suspected anastomotic recurrence of Crohn disease after ileocolic resection: evaluation with CT enteroclysis.

PURPOSE: To determine the utility of computed tomographic (CT) enteroclysis for characterization of the status of the anastomotic site in patients with Crohn disease who had previously undergone ileocolic resection. MATERIALS AND METHODS: Written informed consent was prospectively obtained from all patients, and the institutional review board approved the study protocol. CT enteroclysis findings in 40 patients with Crohn disease who had previously undergone ileocolic resection were evaluated independently by two readers. Endoscopic findings, histopathologic findings, and/or the Crohn disease activity index was the reference standard. Interobserver agreement between the two readers was calculated with kappa statistics. Associations between CT enteroclysis findings and anastomotic site status were assessed at univariate analysis. The sensitivity, specificity, and accuracy of CT enteroclysis, with corresponding 95% confidence intervals (CIs), for the diagnosis of normal versus abnormal anastomosis and the diagnosis of anastomotic recurrence versus fibrostenosis were estimated. RESULTS: Interobserver agreement regarding CT enteroclysis criteria was good to perfect (kappa = 0.72-1.00). At univariate analysis, stratification and anastomotic wall thickening were the two most discriminating variables in the differentiation between normal and abnormal anastomoses (P < .001). Stratification (P < .001) and the comb sign (P = .026) were the two most discriminating variables in the differentiation between anastomotic recurrence and fibrostenosis. In the diagnosis of anastomotic recurrence, severe anastomotic stenosis was the most sensitive finding (95% [20 of 21 patients]; 95% CI: 76.18%, 99.88%), both comb sign and stratification had 95% specificity (18 of 19 patients; 95% CI: 73.97%, 99.87%), and stratification was the most accurate finding (92% [37 of 40 patients]; 95% CI: 79.61%, 98.43%). In the diagnosis of fibrostenosis, both severe anastomotic stenosis and anastomotic wall thickening were 100% sensitive (eight of eight patients; 95% CI: 63.06%, 100.00%), and using an association among five categorical variables, including severe anastomotic stenosis, anastomotic wall thickening with normal or mild mucosal enhancement, absence of comb sign, and absence of fistula, yielded 88% sensitivity (seven of eight patients; 95% CI: 47.35%, 99.68%), 97% specificity (31 of 32 patients; 95% CI: 83.78%, 99.92%), and 95% accuracy (38 of 40 patients; 95% CI: 83.08%, 99.39%). CONCLUSION: CT enteroclysis yields objective and relatively specific morphologic criteria that help differentiate between recurrent disease and fibrostenosis at the anastomotic site after ileocolic resection for Crohn disease. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09091165/-/DC1.

CT enteroclysis features of uncomplicated celiac disease: retrospective analysis of 44 patients.

PURPOSE: To describe the computed tomographic (CT) enteroclysis features of uncomplicated celiac disease (CD) and to determine the most indicative appearance of this condition by using a retrospective case-control study. MATERIALS AND METHODS: This study had institutional review board approval. The CT enteroclysis examinations of 44 consecutive patients with proved uncomplicated CD (21 men, 23 women; mean age, 44.45 years) were reviewed by two blinded readers and compared with those obtained in 44 control subjects (21 men, 23 women; mean age, 44.48 years), who were matched for sex and age. Comparisons were calculated by using univariate analysis. RESULTS: Reversed jejunoileal fold pattern had the highest specificity (100%; 44 of 44; 95% confidence interval [CI]: 91.96%, 100%) and was the most discriminating independent variable for the diagnosis of uncomplicated CD (odds ratio, 39.9; P < .0001) but had a sensitivity of 63.64% (28 of 44; 95% CI: 47.77%, 77.59%). Ileal fold thickening, vascular engorgement, and splenic atrophy were other variables that strongly correlated with the presence of uncomplicated CD. CONCLUSION: CT enteroclysis may help establish a diagnosis of uncomplicated CD and may clarify the cause of nonspecific gastrointestinal symptoms in patients with unknown CD. However, future prospective trials are needed to determine the actual value of CT enteroclysis in patients with CD and validate the clinical usefulness of CT enteroclysis in the detection of unknown uncomplicated CD.

Celiac disease in adults: evaluation with MDCT enteroclysis.

OBJECTIVE: The purpose of this article is to present the MDCT enteroclysis features of the multiple complications of celiac disease and illustrate why this technique is helpful to adult patients with celiac disease. CONCLUSION: MDCT enteroclysis findings can suggest the diagnosis in adult patients with unknown celiac disease, and many complications of celiac disease can be recognized because of their characteristic appearance. Familiarity with these signs can help in appropriate planning of further diagnostic procedures.

Difficulties in assessing cytomegalovirus-associated gastric perforation in an HIV-infected patient.

BACKGROUND: Active Cytomegalovirus (CMV) infection is a common complication in advanced symptomatic Human Immunodeficiency Virus (HIV) infection. CMV-induced intestinal perforations are hard to diagnose and may be observed throughout the gastrointestinal tract. Isolated stomach perforation is exceptional. CASE PRESENTATION: A 47-year-old man was admitted to our intensive care unit with multiorgan failure. Gastrointestinal endoscopic examination showed erythematous gastritis but normal duodenum and colon. CMV blood culture was positive. Histologic examination of a gastric biopsy showed inflammatory infiltrate and immunostaining typical intranuclear CMV inclusion bodies. Concomitant abdominal CT scan disclosed large peripancreatic hypodensities without pneumoperitoneum. The patient died despite supportive therapies and ganciclovir infusion. Postmortem examination showed a 4-cm gastric perforation adhering to the transverse colon and liver, with a thick necrotic inflammatory coating around the pancreas. The whole GI tract, except the stomach, was normal. As other causes, especially Helicobacter pylori infection could be ruled out, a causal relationship between CMV and gastric disease was assumed. CONCLUSION: CMV may be responsible for gastric perforations, with difficulties in assessing the diagnosis. Early diagnosis based on cautious endoscopy and histopathologic examination is needed to make a favorable outcome possible.

Safety and efficacy of extractible self-expandable metal stents in the treatment of Crohn's disease intestinal strictures: a prospective pilot study.

BACKGROUND: Endoscopic management of Crohn's disease (CD) intestinal strictures with balloon dilation is effective; however, recurrences are frequent and require further dilations or surgery. The use of extractible metallic stents may be as effective as balloon dilation with fewer recurrences. The aim was to investigate in a prospective pilot study the feasibility and clinical effectiveness of the use of extractible stents in the treatment of CD intestinal strictures. METHODS: In two tertiary referral centers, quiescent CD patients except for obstructive symptoms associated with intestinal stenosis of less than 50 mm length on enterography were eligible for transitory stent placement, initially planned to be retrieved after 8 weeks, which was secondarily reduced to 4 weeks after patient 3. RESULTS: Eleven patients (six males, five females, median age 34 years [range 18-66]) were prospectively included. The sites of intestinal stenosis were an ileocolonic anastomosis, an ileosigmoidic anastomosis, and the surgically untreated terminal ileum in eight, one, and two patients, respectively. Stent placement was technically successful in 10 patients. Obstructive symptoms were relieved in 6 out of 10 patients. Two patients needed surgery related to the procedure. Six downstream migrations were observed. Only one patient could have the stent extracted as scheduled on day 28 and remains symptom-free after 73 months of follow-up. CONCLUSIONS: Even if stenting appears an effective technique in treating symptomatic CD intestinal strictures, the procedure is associated with a prohibitively high rate of spontaneous migrations and complications.

Cerebral venous thrombosis in inflammatory bowel diseases: eight cases and literature review.

BACKGROUND: While the association between inflammatory bowel diseases and thromboembolic events has long been evident, cerebral venous thrombosis in this context remains rare and underreported. METHODS: Among 351 consecutive patients with cerebral venous thrombosis collected in two neurology departments between 1997 and 2009, an analysis of patients with inflammatory bowel disease and a review of literature were performed. RESULTS: Eight patients had inflammatory bowel disease (6/287, 2/64), Crohn's disease in two, and ulcerative colitis in two. The mean age was 30 · 9 years (18-45). All inflammatory bowel disease-related cerebral venous thrombosis patients had headache, four patients had focal neurological deficits, three had altered consciousness, and two had seizures. Cerebral venous thrombosis occurred between two-months and 17 years after the first inflammatory bowel disease signs. Six patients had other venous prothrombotic risk factors. All patients were treated with heparin or low-molecular-weight heparin. Seven showed a complete recovery (Rankin 0-1) and one a partial recovery (Rankin 2). Compared with the 49 magnetic resonance imaging-confirmed cerebral venous thrombosis patients of the literature, our patients had more frequent associated prothrombotic risk factors. When comparing 57 inflammatory bowel disease-related cerebral venous thrombosis patients with other cerebral venous thrombosis, those with inflammatory bowel disease were younger in age at cerebral venous thrombosis onset, and there was a higher male to female ratio and a lower headache frequency at presentation. CONCLUSION: In our cerebral venous thrombosis cohort, inflammatory bowel disease is present in 2 · 3% of cases. As cerebral venous thrombosis has no specific feature and may reveal inflammatory bowel disease, intestinal signs should be systematically looked for. All physicians caring for inflammatory bowel disease patients must consider cerebral venous thrombosis in cases of unusual headache or focal neurological symptoms. Treatment is based on full anticoagulation and specific inflammatory bowel disease treatment.

Multiple intra-abdominal venous thrombosis in ulcerative colitis: role of MDCT for detection.

Patients with ulcerative colitis are at increased risk for venous thrombosis. We report herein the case of a 28-year-old woman who developed multiple intraabdominal venous thrombosis, including partial Budd-Chiari syndrome in association with intracranial venous thrombosis and pulmonary embolism during the relapse of a known ulcerative colitis. Multidetector-row computed tomography (MDCT) allowed depiction of multiple intraabdominal sites of thrombosis including right and medial hepatic veins, left portal vein, splenic vein and left ovarian vein and demonstrated complete resolution of the multiple thrombi after anticoagulant therapy. The association of partial Budd-Chiari syndrome with other thrombi involving portal, splenic and ovarian veins in association with ulcerative colitis, has, to our knowledge never been reported yet. In addition, the potential role of MDCT in the detection of possible multiple thrombosis in patients with ulcerative colitis has never been emphasized.

Octreotide for recurrent intestinal variceal bleeding in patients without portal hypertension.

We report on the efficacy of octreotide acetate in two patients with intestinal phlebectasia and no evidence of portal hypertension or mesenteric thrombosis. Patient 1 was a 46-year-old woman with primary pulmonary arterial hypertension. She required repeated transfusions for recurrent episodes of gastrointestinal bleeding (GIB). Intraoperative enteroscopy revealed wide-spread small bowel phlebectasia and intestinal resection was not performed. Blue rubber-bleb syndrome, portal hypertension and mesenteric thrombosis were ruled out. Octreotide acetate long-acting release was started. A transient interruption in treatment was followed by severe overt GIB. This was effectively controlled with continuous infusion of octreotide acetate. After this episode, octreotide acetate long-acting release was resumed and no further episodes of GIB have been reported until the most recent follow up (total duration of 74 months). Patient 2 was a 51-year-old woman with a history of recurrent GIB requiring multiple blood transfusions since young adulthood with negative endoscopic investigations. An enteroscopy showed numerous submucosal serpiginous varices in the colon and the terminal ileum. All putative causes including portal hypertension or mesenteric thrombosis were ruled out. Monthly intramuscular injections of long-acting octreotide acetate were initiated, and no GIB occurred since then (27 months of follow up). Somatostatin analogues are known to reduce splanchnic blood flow, to increase vascular resistance, to enhance platelet aggregation; and are thus efficacious in preventing GIB secondary to various vascular lesions (portal hypertension, intestinal angiodysplasia and blue rubber-bleb syndrome). These case reports suggest that they are also effective in preventing GIB in intestinal phlebactasia without portal hypertension.

Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding?

BACKGROUND AND AIMS: The position of capsule endoscopy (CE) relative to push enteroscopy (PE) in the diagnostic algorithm of obscure gastrointestinal bleeding is unclear, as previous studies involved the use of both techniques in all patients. We therefore conducted a trial in which patients were randomized to undergo one or other exploration. METHODS: All consecutive patients referred for obscure gastrointestinal bleeding were randomized between CE and PE as the first-line exploration. The alternative method was only used if the first-line method revealed no definite bleeding source, or if required for clinical reasons during follow-up. RESULTS: CE and PE, used as the first-line exploration, identified a bleeding source in 20 of 40 patients and 9 of 38 patients, respectively (50% vs 24%; P = .02). CE missed lesions in 8% of patients, and all these lesions were located in sites accessible to standard endoscopy. PE missed lesions in 26% of patients. At the end of the 12-month follow-up period, the strategy based on CE as first-line exploration followed by PE if necessary only was similar to PE followed by CE in terms of diagnostic yield, clinical outcome, and therapeutic impact, but reduced the percentage of patients needing the alternative exploration (25% vs 79%; P < .001). CONCLUSIONS: CE has a higher diagnostic yield than PE in obscure gastrointestinal bleeding, and a strategy based on CE as first-line exploration avoids unnecessary explorations.

Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial.

BACKGROUND: In chronic pancreatitis, obstruction of the main pancreatic duct (MPD) may contribute to the pathogenesis of pain. Pilot studies suggest that extracorporeal shock wave lithotripsy (ESWL) alone relieves pain in calcified chronic pancreatitis. AIM: To compare ESWL alone with ESWL and endoscopic drainage of the MPD for treatment of pain in chronic pancreatitis. SUBJECTS: Patients with uncomplicated painful chronic pancreatitis and calcifications obstructing the MPD. METHODS: 55 patients were randomised to ESWL alone (n = 26) or ESWL combined with endoscopy (n = 29). RESULTS: 2 years after trial intervention, 10 (38%) and 13 (45%) patients of the ESWL alone and ESWL combined with endoscopy group, respectively, had presented pain relapse (primary outcome) (OR 0.77; 95% CI 0.23 to 2.57). In both groups, a similar decrease was seen after treatment in the MPD diameter (mean decrease 1.7 mm; 95% CI 0.9 to 2.6; p<0.001), and in the number of pain episodes/year (mean decrease, 3.7; 95% CI 2.6 to 4.9; p<0.001). Treatment costs per patient were three times higher in the ESWL combined with endoscopy group compared with the ESWL alone group (p = 0.001). The median delay between the onset of chronic pancreatitis and persistent pain relief for both groups was 1.1 year (95% CI 0.7 to 1.6), as compared with 4 years (95% CI 3 to 4) for the natural history of chronic pancreatitis in a reference cohort (p<0.001). CONCLUSIONS: ESWL is a safe and effective preferred treatment for selected patients with painful calcified chronic pancreatitis. Combining systematic endoscopy with ESWL adds to the cost of patient care, without improving the outcome of pancreatic pain.

Plasma citrulline: A marker of enterocyte mass in villous atrophy-associated small bowel disease.

BACKGROUND & AIMS: Plasma citrulline, a nonprotein amino acid produced by enterocytes, was suggested as a marker of remnant enterocyte mass in patients with short bowel. Our objective was to evaluate citrulline as a marker of severity and extent of villous atrophy in patients without intestinal resection. METHODS: Forty-two patients with celiac disease and 10 patients with non-celiac villous atrophy disease were studied by plasma postabsorptive citrulline and biological dosages, biopsies of proximal (duodenojejunal) small bowel and distal ileum (n = 25), or measurement of vitamin B(12) absorption (n = 4). Nine patients were reevaluated after following a gluten-free diet for 1 year. Controls were 51 healthy subjects and 10 severely malnourished patients with anorexia nervosa with no intestinal mucosal abnormalities. RESULTS: Plasma citrulline concentration was lower (P < 0.001) in patients with villous atrophy (24 +/- 13 micromol/L) than in healthy subjects (40 +/- 10 micromol/L) and patients with anorexia nervosa (39 +/- 9 micromol/L). Three thresholds were individualized: <10 micromol/L for patients with diffuse total villous atrophy (n = 10), 10-20 micromol/L for patients with proximal-only total villous atrophy (n = 12), and 20-30 micromol/L for patients with partial villous atrophy (n = 10). Plasma citrulline concentration was correlated to the severity and extent of villous atrophy (r = 0.81; P < 0.001) and to albuminemia (r = 0.47; P < 0.01). Receiver operating characteristic curves indicated that plasma citrulline concentration was the best biological variable to predict villous atrophy. Following a 1-year gluten-free diet, plasma citrulline concentration increased in histologically responsive (n = 6) but not in unresponsive (n = 3) patients. CONCLUSIONS: In patient villous atrophy diseases, plasma citrulline concentration may prove to be a simple and reliable marker of reduced enterocyte mass.

Low-dose growth hormone in adult home parenteral nutrition-dependent short bowel syndrome patients: a positive study.

BACKGROUND & AIMS: Controversy surrounds a 3-week treatment with a high-dose (0.14 mg. kg(-1). day(-1)) growth hormone (GH), glutamine, and high carbohydrate diet in home parenteral nutrition (HPN)-dependent patients with short-bowel syndrome (SBS). This study assessed treatment with low-dose GH in these patients. METHODS: Twelve adult HPN-dependent (duration, 7 +/- 1 years; mean +/- SEM) patients with SBS (small-bowel remnant length, 48 +/- 11 cm) who were on an unrestricted hyperphagic diet were randomized in a double-blind, placebo-controlled, crossover study. Patients received daily low-dose GH (0.05 mg. kg(-1). day(-1)) and placebo for two 3-week periods separated by a 1-week washout period. Net intestinal absorption of macronutrients was assessed using a duplicate diet; nutritional assessment and blood tests were performed. Data from each group were compared using Wilcoxon rank sum test. RESULTS: Treatment with GH increased intestinal absorption of energy (15% +/- 5%, P < 0.002), nitrogen (14% +/- 6%, P < 0.04), carbohydrates (10% +/- 4%, P < 0.04), and fat (12% +/- 8%, NS). The increased food absorption represented 37% +/- 16% of total parenteral energy delivery. Body weight (P < 0.003), lean body mass (P < 0.006), D-xylose absorption (P < 0.02), insulin-like growth factor 1 (P < 0.002), and insulin-like growth factor binding protein 3 (P < 0.002) increased, whereas uptake of GH binding protein decreased (P < 0.01), without any major adverse effect. CONCLUSIONS: Three weeks of low-dose GH significantly improved intestinal absorption in HPN-dependent SBS patients who were on a hyperphagic western diet.