Capsule endoscopy and enteroscopy: modern modalities to investigate the small bowel in paediatrics.
ABSTRACT Historically the small bowel has been considered a technically difficult area to examine because of its length (3-5 metres), location and tortuosity. Capsule endoscopy and enteroscopy have revolutionised the investigation pathway of the small bowel in adults. They are now developing increasingly important roles as modalities of investigation in paediatrics. This review appraises the current literature to define the clinical indications and practical aspects of capsule endoscopy and enteroscopy that are of interest to the clinician.
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ABSTRACT: Diagnostic and therapeutic benefits of double-balloon enteroscopy (DBE) have been documented in adults with little pediatric data available. We evaluated the diagnostic and therapeutic utility of DBE in children. A Prospective assessment of 113 DBE procedures in 58 consecutive children < 18 years (M=36, F = 22; median age 12.7 years, range 1-18 years) were performed for a variety of suspected small bowel disorders from Jan 2008 to August 2012 in a pediatric tertiary referral centre. All children had undergone prior upper GI endoscopy and ileo-colonoscopy. 19 patients had undergone radiological investigations of small bowel (n = 11 MRI; n = 5 Barium; n = 3 CT) and 54 patients wireless capsule endoscopy (WCE). The overall median (range) examination time was 92.5 (45-275) minutes. The median (range) estimated insertion length of small bowel distal to pylorus was 230 (80-450) cm and proximal to ileocecal valve was 80 (5-275) cm. The common indications for DBE were polyposis syndromes (n = 21) and obscure GI bleeding (n = 16). The findings included polyps (n = 19), mucosal ulcers and erosions (n = 8), sub mucosal elevations with white nodules (n = 4), and angioma/angiodysplasia (n = 2). The overall diagnostic yield for small bowel lesions using DBE was 70.7% (41/58) and 77.7% (42/54) with WCE. Endo-therapeutic intervention was successfully utilized in 46.5% (n = 27/58). The endoscopic, medical and surgical contribution to change in management by DBE was 72.4% (n = 42/58). Three complications (5.2%) were noted with uneventful recovery. Diagnostic yield of DBE was comparable to WCE but with addition of therapeutic possibility and histological yield. We believe this technique could be a valuable addition to existing endoscopic techniques, complimentary to WCE and may be considered as an alternative diagnostic and therapeutic option in the small bowel in children.Journal of pediatric gastroenterology and nutrition 10/2013; · 2.18 Impact Factor
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ABSTRACT: Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in inflammation, stricturing and fistulae secondary to transmural inflammation. Diagnosis relies on clinical history, abnormal laboratory parameters, characteristic radiologic and endoscopic changes within the gastrointestinal tract and most importantly a supportive histology. The article is intended mainly for the general gastroenterologist and for other interested physicians. Management of small bowel CD has been suboptimal and limited due to the inaccessibility of the small bowel. Enteroscopy has had a significant renaissance recently, thereby extending the reach of the endoscopist, aiding diagnosis and enabling therapeutic interventions in the small bowel. Radiologic imaging is used as the first line modality to visualise the small bowel. If the clinical suspicion is high, wireless capsule endoscopy (WCE) is used to rule out superficial and early disease, despite the above investigations being normal. This is followed by push enteroscopy or device assisted enteroscopy (DAE) as is appropriate. This approach has been found to be the most cost effective and least invasive. DAE includes balloon-assisted enteroscopy, [double balloon enteroscopy (DBE), single balloon enteroscopy (SBE) and more recently spiral enteroscopy (SE)]. This review is not going to cover the various other indications of enteroscopy, radiological small bowel investigations nor WCE and limited only to enteroscopy in small bowel Crohn's. These excluded topics already have comprehensive reviews. Evidence available from randomized controlled trials comparing the various modalities is limited and at best regarded as Grade C or D (based on expert opinion). The evidence suggests that all three DAE modalities have comparable insertion depths, diagnostic and therapeutic efficacies and complication rates, though most favour DBE due to higher rates of total enteroscopy. SE is quicker than DBE, but lower complete enteroscopy rates. SBE has quicker procedural times and is evolving but the least available DAE today. Larger prospective randomised controlled trial's in the future could help us understand some unanswered areas including the role of BAE in small bowel screening and comparative studies between the main types of enteroscopy in small bowel CD.World journal of gastrointestinal endoscopy. 10/2013; 5(10):476-486.
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ABSTRACT: To evaluate the role of wireless capsule endoscopy in identifying small bowel lesions in pediatric patients with newly diagnosed colonic inflammatory bowel disease (IBD) type unclassified (IBDU), and to assess whether capsule endoscopy findings result in altered patient management. Ten pediatric patients recently diagnosed with IBDU through standard investigations were recruited from the pediatric gastroenterology clinic at McMaster Children's Hospital to undergo capsule endoscopy using the Pillcam SB(TM) (Given Imaging) capsule. Findings consistent with a diagnosis of Crohn's disease required the identification of at least three ulcerations. Three out of ten patients had newly identified findings on capsule endoscopy that met criteria for Crohn's disease. Three more patients had findings suspicious for Crohn's disease, but failed to meet the diagnostic criteria. Three additional patients had findings most consistent with ulcerative colitis, and one had possible gastritis with a normal intestine. Findings from capsule endoscopy allowed for changes in the medical management of three patients. In all ten cases, capsule endoscopy allowed for a better characterization of the type and extent of disease. No adverse outcomes occurred in the present cohort. This prospective study reveals that wireless capsule endoscopy is feasible, valuable, and non-invasive, offering the ability to potentially better characterize newly diagnosed pediatric IBDU cases by identifying lesions in the small bowel and reclassifying these as Crohn's disease.Jornal de pediatria 07/2013; 89(2):204-9. · 1.07 Impact Factor