Capsule endoscopy for the small bowel in juvenile polyposis syndrome: a case series.

Juvenile polyposis syndrome is one of the hamartomatous polyposis syndromes and demonstrates phenotypic heterogeneity. All patients with juvenile polyposis develop colorectal polyps and are at risk of colorectal cancer. Small-bowel involvement is variably described. Small-intestinal cancer is reported but is rare and there is no evidence-based protocol for small-intestinal surveillance. This case series reports the small-bowel capsule endoscopy findings and genetic mutational analyses of ten adults (7-male; median age 39.2 years, interquartile range 37.4 - 42.0 years) with documented juvenile polyposis syndrome. Two patients had small-bowel polyps beyond the range of standard gastroscopy identified at capsule endoscopy: a 6-mm ileal polyp in one, and 10-mm and 6-mm ileal polyps in the second (histology unknown). Duodenal polyps were detected in a third patient at capsule endoscopy. Three further patients had previously documented duodenal polyps at surveillance gastroscopy. A SMAD4 mutation was identified in seven patients but there was no obvious association with gastric/small-bowel polyp burden. In conclusion, capsule endoscopy provided information additional to conventional endoscopy in patients with juvenile polyposis syndrome and was well tolerated. However, no lesions requiring clinical intervention were identified and polyp numbers were small. Capsule endoscopy may appropriately be used as a baseline investigation for the identification of patients with large or dense small-bowel polyps for whom ongoing small-bowel investigation would be recommended. Patients in whom polyps are confined to the colon are unlikely to require ongoing small-bowel review.

The impact of experience on polyp detection and sizing accuracy at capsule endoscopy: implications for training from an animal model study.

BACKGROUND AND STUDY AIMS: Indications for capsule endoscopy include polyp surveillance in Peutz-Jeghers syndrome and potentially colorectal examination and bowel cancer screening. The ability to detect and accurately size polyps associated with these conditions is critical when deciding which patients require further investigation or therapy. Inexperience may affect the ability of capsule endoscopists to perform these skills resulting in sub-optimal patient care. We assessed the performance of volunteers with different levels of endoscopy and capsule endoscopy experience using an animal-based polyp model. PATIENTS AND METHODS: Thirty-six artificial polyps were sewn onto the luminal surface of porcine small bowel through which a capsule was propelled. Video images generated by the capsule were then shown to five expert capsule endoscopists, seven consultant gastroenterologists, seven trainee gastroenterologists, six endoscopy nurses, six gastrointestinal radiologists, and six nonmedical participants. Polyp detection rates and sizing accuracy were calculated according to each group and compared. RESULTS: Expert capsule endoscopists had the highest polyp detection rate (91%) but only noncapsule endoscopy experience was independently correlated with improved polyp detection and sizing accuracy (OR missing polyp--endoscopy experience 1.0, no experience 1.96 [95% CI 1.29 - 2.97], P = 0.002; ratio of estimated to actual size--endoscopy experience 1.0, no experience 1.43 [95% CI 1.22 - 1.66], P < 0.001). Both expert capsule endoscopists and experienced endoscopists tended to underestimate polyp size more than novices, particularly for large polyps (OR capsule expert to non-expert: 2.39 vs. 1.0 [95% CI 1.73 - 3.29], P < 0.001). CONCLUSIONS: Polyp detection rates and sizing accuracy during capsule endoscopy improve with endoscopic experience. However large polyps, which are the most clinically relevant, are least-accurately sized, and capsule endoscopy experts and experienced endoscopists are the most likely to underestimate the size of these polyps. Training to improve performance in these measures for capsule endoscopy novices as well as experts is required.

Argon plasma coagulation in chronic radiation proctitis.

Chronic radiation proctitis is a relatively common late complication of pelvic irradiation. The main symptoms are diarrhea, urgency, tenesmus, and rectal bleeding. While mild cases may settle spontaneously over some months, severe hemorrhagic radiation proctitis may require repeated blood transfusions and is difficult to treat with medical therapy. Argon plasma coagulation (APC) is a noncontact thermal coagulation technique which can be applied endoscopically. A probe passed through the scope delivers a field of argon gas to the mucosal surface where it is ionized by a high voltage filament, resulting in superficial mucosal heating and coagulation of friable blood vessels. The technique reduces rectal bleeding in 80%-90% of cases, and may improve the other troublesome symptoms of diarrhea and urgency. APC is probably less effective in very severe cases of hemorrhagic radiation proctitis; in these cases topical formalin or a combination of APC and topical formalin can be useful. Overall, APC has proved to be a safe and well tolerated technique.