Is the capsule a guiding star ?

Dr. Niv EvaDepartment of Gastroenterology

Tel-Aviv Sourasky Medical Center

First Case

44 y.o. woman

13 years agoAbdominal pain, diarrheaNormal colonoscopy+ileoscopy (including biopsies)Small bowel passage– thickening of middle part of small bowel

Diagnosis: Crohn’s disease of mid- small intestine

Treatment:Azathioprine ( 3-4 y)– good response, but leukopenia stopped5ASA, prednisone– good responseRecently asymptomatic all medications stopped

10 months ago

Abdominal pain, diarrhea, weight loss

Hypokalemia, hypomagnesemia, anemia,

hypoalbuminemia (3.0 g/dL)

Two weeks later– hospitalization

small intestinal intussusception

CT:

Thickening of all small intestine

(especially – mid),

mesenteric lymphadenopathy

Conservative treatment

Resolution of intussusception discharge

Follow up visit in the Dept of Gastroenterology

Looks ill, still abdominal pain

severe diarrhea (~2000 cc of stool/day),

weight loss (6-7 kg), BMI 19,

hypoalbuminemia (2.7 g/dL)

• Ileo-colonoscopy– normal

• Normal biopsies from colon and terminal ileum

• Video capsule endoscopy (another medical center)

Normal Small Intestinal Mucosa.

Revision of the film …

Normal small intestinal mucosa

What is the diagnosis of the patient?

Scalloped folds, lack of villi, mosaic patternDiagnosis—

Celiac disease

DD: Lymphoma, Mastocytosis, Eosinophilic gastroenteritis, Hypogammaglobulinemia, Giardiasis, Tropical sprue

Enteroscopy

The mystery was resolved:• No evidence of Crohn’s disease• The recent deterioration was explained by wheat-

based diet• Celiac disease is a known cause of

intussusception

Gluten-free diet was started with

quick improvement

Anti TTG positive (high titer)The diagnosis of celiac disease was established

The possibility of T cell lymphoma was excluded

Folow up in 10 months

• The patient adheres to gluten-free diet • The patient is asymptomatic• Normal nutritional state, normal blood

tests

Summary of First Case

• In this case capsule endoscopy was a blessing by finding the right diagnosis when other imaging tests were misleading.

Endoscopy 2005ICCE Consensus for Celiac Disease

,,All video capsule endoscopists need to be familiar with the changes characteristic of celiac disease.’’

Indications for capsule endoscopy in celiac disease:1. Persistent or alarm symptoms in patients with

established celiac disease2. Initial diagnosis in patient with positive celiac

serology who is unwilling or unable to undergo EGD

Second Case

• 74 y.o. male• IHD, s/p CABG X2, recently asymptomatic• PAF• Medications: amiodarone, clopidogrel

• 2 y.a.– Laparoscopic inguinal hernia repair• 1 y.a.—Small bowel obstruction

Laporoscopic adhesiolysis

(a few adhesions in unrelated area)

During the following 6 months–

Recurrent episodes of small intestinal obstruction

Conservative treatment

CT abdomen– Thickening and mild dilation of mid-small intestinal loop

•On the basis of clinical picture surgery was planned

•But the surgeon asked to perform capsule endoscopy first

Small submucosal lesion

Discrete areas of inflammation and erosions

Stricturing ulcers

What is the differential diagnosis of the patient?

What should be the strategy?

DD

• Crohn’s disease

• NSAIDs or other medications

• Lymphoma

• TB

• Ischemia due to atherosclerosis

or intermittent intussusception (submucosal tumors, adhesions)

• Ulcerative jejunoileitis

Work-up

• No medications except for amiodarone and clopidogrel

• Lab tests– CBC, SMA, CRP normal• Colonoscopy (including biopsies)– normal• Gastroscopy– normal• Enteroscopy (including biopsies)– normal• ASCA, ANCA negative

The dilemma:

To operate or to give empirical treatment

Decision– prednisone trialprednisone 40 mgx1 for 2 weeks—failureTapering down

Operation

No evidence of Crohn’s disease (no transmural inflammation, no fat wrapping)

No evidence of lymphoma (no lymphadenopathy)

Normal small bowel (outside view)

Multiple adhesions with segmental pressure on small bowel

Biopsy from adhesions: Fibrotic tissue. No granulomas

Suggestion: adhesions and recurrent episodes of small bowel obstruction caused secondary ischemic changes in the bowel

Am J Surg 2005; 190: 886-90

The utility of capsule endoscopy and its role for diagnosing pathology in the GI tract

Carlo JT et al

Follow up in 6 months

• The patient is asymptomatic

• No additional events of small bowel obstruction

Summary of Second Case

• In this case capsule endoscopy delayed the definitive treatment (operation) by several months

Thank you for your attention