Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy

• Published in: Gastrointestinal endoscopy 2008-12, Vol.68 (6), p.1209-1214
• Main Authors: Postgate, Aymer, MRCP, Despott, Edward, MRCP, Burling, David, MD, Gupta, Arun, MD, Phillips, Robin, MS, FRCS, O'Beirne, James, MD, Patch, David, MD, Fraser, Chris, MD
• Format: Article
• Language: English
• Subjects: Adult; Aged; Biological and medical sciences; Capsule Endoscopy; Digestive system. Abdomen; Endoscopy; Endoscopy, Gastrointestinal; False Negative Reactions; Female; Gastroenterology and Hepatology; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Intestinal Diseases - diagnosis; Intestine, Small - pathology; Investigative techniques, diagnostic techniques (general aspects); Magnetic Resonance Imaging; Male; Medical sciences; Retrospective Studies; Tomography, X-Ray Computed
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/j.gie.2008.06.035

Background Capsule endoscopy (CE) is considered a first-line investigation for obscure GI bleeding (OGIB) and small-bowel polyp or tumor detection. The reliability of a negative CE in excluding gross small-bowel pathology remains unclear. New imaging modalities, such as double-balloon enteroscopy (DBE), CT enterography (CTE) or magnetic resonance enterography (MRE) now provide complementary roles to CE for these indications. Objective We describe our experience of significant small-bowel pathology missed at CE in 5 patients. The lesions were subsequently detected by DBE, CTE, or MRE. Design A retrospective case series. Setting Single-center academic endoscopy unit in a tertiary-referral hospital. Patients Five patients were evaluated: 4 with a history of OGIB (transfusion dependent in 2) and 1 patient with Peutz-Jeghers syndrome (PJS) under small-bowel surveillance. Interventions CE was performed in all patients. Further evaluation via DBE, CTE, or MRE was performed. Definitive treatment was carried out by enteroscopic polypectomy (1 patient), surgical resection (2 patients), and transjugular intrahepatic portosystemic shunt procedure and embolization (1 patient). Main Outcome Measurements Detection of significant small-bowel pathology by using DBE, CT, or MRE after a negative capsule study. Results Significant small-bowel pathology was missed at CE but was detected by alternative modalities in 5 patients. In 4 patients, the lesions were in the proximal small bowel (adenocarcinoma, malignant melanoma, varices, and stromal tumor). The fifth patient had a large PJS polyp in the proximal ileum. Limitations Retrospective case series with small numbers. Conclusions Gross pathology may be missed at CE, especially in the proximal small bowel, and a negative CE study does not exclude significant disease. Alternative imaging modalities, such as DBE, CTE, or MRE, should be considered when clinical suspicion persists.