Figure - available from: Journal of Clinical Medicine (JCM)
This content is subject to copyright.
(a) The area under the receiver operating characteristic (ROC) curve for combined expert and novice mucosal protrusion angle using a cutoff of <90° for true mass. (b) The area under the ROC curve for smooth, protruding lesion at capsule endoscopy (SPICE) index using a cutoff of >2 for true mass.
Source publication
The diagnosis of small-bowel tumors is challenging due to their low incidence, nonspecific presentation, and limitations of traditional endoscopic techniques. In our study, we examined the utility of the mucosal protrusion angle in differentiating between true submucosal masses and bulges of the small bowel on video capsule endoscopy. We retrospect...
Similar publications
Automatically generating maps from satellite images is an important task. There is a body of literature which tries to address this challenge. We created a more expansive survey of the task by experimenting with different models and adding new loss functions to improve results. We created a database of pairs of satellite images and the correspondin...
Citations
... Lesions in the duodenum and proximal jejunum are easily missed because of the rapid transit of the capsule through these areas. Sometimes transient bulges in the small bowel lumen may appear to be submucosal masses [70][71][72][73]. The main disadvantage of VCE is that it does not permit tissue sampling. ...
A retrospective study in patients who underwent video capsule endoscopy (VCE) between 2006 and 2016 was conducted in the Clinic for gastroenterology and Hepatology, University Clinical Center of Serbia. A total of 245 patients underwent VCE. In 198 patients the indication was obscure gastrointestinal bleeding (OGIB), with 92 patients having overt and the other 106 occult bleeding. The remaining 47 patients underwent VCE due to suspected small bowel (SB) disease (i.e., Von Hippel–Lindau syndrome, familial adenomatous polyposis, Peutz Jeghers syndrome, Crohn’s disease, prolonged diarrhea, abdominal pain, congenital lymphangiectasia, protein-losing enteropathy, tumors, refractory celiac disease, etc.). VCE identified a source of bleeding in 38.9% of patients (in the obscure overt group in 48.9% of patients, and in the obscure occult group in 30.2% of patients). The most common findings were angiodysplasias, tumors, Meckel’s diverticulum and Crohn’s disease. In the smaller group of patients with an indication other than OGIB, 38.3% of patients had positive VCE findings. The most common indication is OGIB, and the best candidates are patients with overt bleeding; patients with IBD should be evaluated in this setting.
... Therefore, the timely and accurate diagnosis and localization of SBMLs is crucial. Nevertheless, the diagnosis of SBMLs is difficult owing to their low incidence, nonspe- cific clinical presentation, and location beyond the reach of standard endoscopic evaluation [1,3]. Indeed, up until the past two decades, these lesions were typically only diagnosed with surgical laparotomy [4,5]. ...
... Since its approval in 2001, video capsule endoscopy (VCE) has played a significant role in detecting SBMLs in patients presenting with a variety of complaints ranging from occult GI bleeding to abdominal pain and weight loss. As it typically allows for inspection of the entire small bowel and has a diagnostic yield as high as 91% for detecting SBMLs, the incidence of detected SBMLs increased from 11.8 cases per million in 1973 to 22.7 cases per million in 2004 [3][4][5][6][7][8][9]. Though VCE has become the preferred first-line method for luminal small bowel evaluation, it is limited by its inability to provide a tissue diagnosis [1,3,8,10]. ...
... As it typically allows for inspection of the entire small bowel and has a diagnostic yield as high as 91% for detecting SBMLs, the incidence of detected SBMLs increased from 11.8 cases per million in 1973 to 22.7 cases per million in 2004 [3][4][5][6][7][8][9]. Though VCE has become the preferred first-line method for luminal small bowel evaluation, it is limited by its inability to provide a tissue diagnosis [1,3,8,10]. To this end, the introduction of device-assisted enteroscopy (DAE) in 2000 provided a non-surgical, endoscopic modality that allowed for the direct examination of the entire small bowel [11,12]. ...
Background:
Small bowel mass lesions (SBMLs) are rare, span a range of different histologies and phenotypes, and our understanding of them is limited. Some lesions occur in patients with recognized polyposis syndromes and others arise sporadically. The current literature regarding SBMLs is limited to small retrospective studies, case reports, and small case series. This large multi-center study aims to understand the various clinical presentations, histologies and management options for SBMLs.
Methods:
After obtaining Institutional Review Board (IRB) approval, electronic records were used to identify all device-assisted enteroscopy (DAE) performed for luminal small bowel evaluation in adult patients at three US referral centers (Duke, LSU and UMass) from January 1, 2014, to October 1, 2020. We identified all patients within this cohort in whom a SBML was detected. Using a focused electronic medical record chart review, we collected patient, procedure, and lesion-related data and used descriptive statistics to explore relationships between these data and outcomes.
Results:
A total of 218 patients (49 at Duke, 148 at LSU, and 21 at UMass) in this cohort had at least one SBML found on DAE. The most common presenting symptoms were iron-deficiency anemia/bleeding (73.3%) and abnormal imaging (33.6%). Thirty-five percent of patients had symptoms for more than a year prior to their diagnosis. Most patients (71.6%) underwent video capsule endoscopy (VCE) prior to DAE and 84% of these exams showed the lesion. The lesion was seen less frequently (48.9%) on computed tomography (CT) scan performed prior to DAE. The majority of lesions were found on antegrade (56%) or retrograde (29.8%) double-balloon enteroscopy (DBE). The most common lesion phenotypes were submucosal (41.3%) and pedunculated (33%) with a much smaller number being sessile (14.7%) or obstructing/invasive (11%). They were found equally as commonly in the jejunum (46.3%) and ileum (49.5%). Most lesions were 10 - 20 mm in size (47%) but 22.1% were larger than 20 mm. The most common histologies were neuroendocrine tumors (NETs, 20.6%) and hamartomas (20.6%). Primary adenocarcinoma of the small bowel was rare, constituting only 5% of lesions. The majority of polyps (78.4%) were sporadic, compared to 21.7% associated with a polyposis or hereditary cancer syndrome, most commonly Peutz-Jeghers syndrome (18.3%). After DAE, 37.6% were advised to undergo surgical resection and 48% were advised to undergo endoscopic surveillance or no further management because of benign histology or successful endoscopic resection.
Conclusions:
In this multi-center retrospective study we found that SBMLs are more likely to be sporadic than syndromic, medium in size and either pedunculated or submucosal. NETs and hamartomas predominated and symptoms, most commonly anemia, can be present for more than a year prior to diagnosis. Close to one half of lesions required either no further intervention or only endoscopic surveillance.
... Regarding the distinction between innocent bulging (not clinically relevant) and submucosal masses (clinically relevant) detected at SBCE, three different scores (known as smooth, protruding lesions index on capsule endoscopy [SPICE-score], Shyung score, and protruding angle score) have been proposed [85][86][87]. The SPICE score is the only one for which a clinical validation has been performed [ 88 ] and some studies are available. ...
Background
Enteroscopy plays an important role in the management of small bowel bleeding. However, current guidelines are not specifically designed for small bowel bleeding and recommendations from different international societies do not always align. Consequently, there is heterogeneity in the definitions of clinical entities, clinical practice policies, and adherence to guidelines among clinicians. This represents an obstacle to providing the best patient care and to obtain homogeneous data for clinical research.
Aims
The aims of the study were to establish a consensus on the definitions of bleeding entities and on the role of enteroscopy in the management of small bowel bleeding using a Delphi process.
Methods
A core group of eight experts in enteroscopy identified five main topics of small bowel bleeding management and drafted statements on each topic. An expert panel of nine gastroenterologists participated in three rounds of the Delphi process, together with the core group.
Results
A total of 33 statements were approved after three rounds of Delphi voting.
Conclusion
This Delphi consensus proposes clear definitions and a unifying strategy to standardize the management of small bowel bleeding. Furthermore, it provides a useful guide in daily practice for both clinical and technical issues of enteroscopy.
... The SPICE Score ranges between 0 and 4 and a score > 2 is usually considered as suggestive of a true SEM [5] . The second score is the mucosal protrusion angle (MPA), where the authors suggest that an angle > 90 °, is more likely to be a bulge while an angle < 90 °was suggestive of an underlying SEM [6] . The MPA was defined as the angle between the protruding lesion and surrounding mucosa and was calculated by putting a protractor on the screen. ...
... In the MPA study ( n = 34; SEM = 25), the authors demonstrated that an angle < 90 °had a high sensitivity (92.0%) and specificity (88.9%) for distinguishing between true SEM from bulges ( p = 0.0 0 01) [6] . In the study by Afecto et al., the specificity for the MPA was 52.9% with a sensitivity of 88.2% [12] . ...
Aims
The primary aim of this study was to assess the reliability, intra- and inter-observer variation of the SPICE, Mucosal protrusion angle (MPA) and SHYUNG scores in differentiating a subepithelial mass (SEM) from a bulge.
Methods
This retrospective multicentre study analysed the 3 scores, radiological studies, enteroscopy and/or surgical findings.
Results
100 patients with a potential SEM (mean age 57.6years) were recruited with 75 patients having pathology. In patients with a SEM the mean SPICE score was 2.04 (95% CI 1.82–2.26) as compared to 1.16 (95% CI 0.81–1.51) without any pathology (AUC 0.74, p<0.001), with a fair intra-observer agreement (Kappa 0.3, p<0.001) and slight inter-observer agreement (Kappa 0.14, p<0.05). SPICE had a 37.3% sensitivity and 92.0% specificity in distinguishing between a SEM and bulge, whereas MPA<90˚ had 58.7% and 76.0% respectively, with poor intra-observer(p = 0.05) and interobserver agreement (p = 0.64). The SHYUNG demonstrated a moderate intra-observer (Kappa 0.44, p<0.001) and slight inter-observer reliability (Kappa 0.18, p<0.001). The sensitivity of an elevated SHYUNG score (≥4) in identifying a SEM was 18.7% with a specificity of 92.0% (AUC 0.71, p = 0.002).
Conclusions
Though these scores are easy to use, they have, at best, slight to moderate intra and inter-observer agreement. Their overall diagnostic performances are limited.
... Malignancy is more frequent in SBTs, with the most common histological diagnoses being adenocarcinoma, neuroendocrine tumors, gastrointestinal stromal tumors (GISTs) and lymphoma [3]. SBTs are characterized by a lengthy silence-period, nonspecific symptoms and a high degree of malignancy [1,4]. Therefore, studies that focus on the prognosis of SBTs are largely restricted. ...
Background This study aims to explore a deep learning (DL) algorithm for developing a prognostic model and perform survival analyses in SBT patients. Methods The demographic and clinical features of patients with SBTs were extracted from the Surveillance, Epidemiology and End Results (SEER) database. We randomly split the samples into the training set and the validation set at 7:3. Cox proportional hazards (Cox-PH) analysis and the DeepSurv algorithm were used to develop models. The performance of the Cox-PH and DeepSurv models was evaluated using receiver operating characteristic curves, calibration curves, C-statistics and decision-curve analysis (DCA). A Kaplan–Meier (K–M) survival analysis was performed for further explanation on prognostic effect of the Cox-PH model. Results The multivariate analysis demonstrated that seven variables were associated with cancer-specific survival (CSS) (all p < 0.05). The DeepSurv model showed better performance than the Cox-PH model (C-index: 0.871 vs. 0.866). The calibration curves and DCA revealed that the two models had good discrimination and calibration. Moreover, patients with ileac malignancy and N2 stage disease were not responding to surgery according to the K–M analysis. Conclusions This study reported a DeepSurv model that performed well in CSS in SBT patients. It might offer insights into future research to explore more DL algorithms in cohort studies.
... This proposed score can help in the setting of mucosal alterations but the problem of SBSL with normal overlying mucosa still remains. To address this issue, two scores by Girelli C et al (11) and Min M et al (12) were proposed. ...
... SBT may be easier to identify if they show suspicious features, such as bleeding, mucosal disruption, an irregular surface, color and white villi, as proposed by Shyung L et al (10). The problem still remains for smooth protruding lesions covered by normal appearing mucosa and in this sense two scores were proposed to help make the distinction from SBSL and innocent bulges (11,12). ...
... The retrospective nature is subject to confounding and selection bias and our patient sample is small. Nevertheless, this study design is in line with most of works performed in this line of investigation (7,8,10,12,13,17). This is explained by the low incidence of small bowel tumors and the very nature of capsule endoscopy, in which retrospective review of the studies is possible and readily accessible. ...
Introduction and aim:
in capsule endoscopy (CE), small bowel subepithelial lesions (SBSL) are difficult to distinguish from innocent mucosal protrusions. The SPICE score (smooth, protruding lesions index on CE) and a score that assesses the SBSL protrusion angle were developed. The aim of the study was to determine if a composite score is superior to the proposed models.
Methods:
all CE between 01/2010 and 12/2020 were included in the study if a smooth, round protruding lesion was identified. Both scores and a composite score (SPICE > 2 and angle < 90°) were calculated after video review. Mucosal protrusions were defined as SBSL if they had a histological/imaging diagnosis and innocent protrusions if otherwise. All patients without at least one appointment and an additional diagnostic exam after CE were excluded.
Results:
a total of 34 CE were included; 64.7 % were males, aged 65.4 ± 14.7 years. The most common indication for CE was anemia (52.9 %). SBSL was identified in 17 cases, with lipomas (14.7 %) being the most frequent diagnosis. Both the SPICE (AUROC 0.90, p < 0.001) and protrusion angle scores (AUROC 0.74, p = 0.019) accurately distinguished SBSL from innocent protrusions. Applying a 90° cut-off, the protrusion angle had a sensitivity of 52.9 % and specificity of 88.2 %. Applying a cut-off of > 2 points, the SPICE score has a sensitivity of 64.7 % and specificity of 94.2 %. The composite score had a sensitivity, specificity, positive and negative predictive value of 47.0 %, 100 %, 100 % and 65.4 %.
Conclusion:
we propose that additional follow-up investigation should always be undertaken in cases where both a SPICE > 2 and angle of < 90° are obtained, as the likelihood of SBSL is high.
... Twenty-five of 34 patients had a pathologic diagnosis of a tumor. In comparison with SPICE criteria, an angle lesser than 90 degrees had the same specificity but a higher sensitivity (92 % vs 32 %) in their series [108]. In this study, the final diagnostic assessment of patients diagnosed as IB, and the length of follow-up were unclear. ...
Capsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2 3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4 5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.
Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8 9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.
Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.
... Key Words: small bowel endoscopy, single-balloon enteroscopy, double-balloon enteroscopy, spiral enteroscopy, diagnostic yield (J Clin Gastroenterol 2021;55:792-797) S ince its approval for clinical use in 2001, video capsule endoscopy (VCE) has been an invaluable tool in detecting small bowel (SB) pathology. [1][2][3] The rapid adoption of VCE brought a need to be able to directly investigate the findings detected deep in the SB lumen. In 2001, Yamamoto et al 4 introduced the first nonsurgical, device-assisted endoscopic modality that allowed for direct, controlled examination of the entire SB using the double-balloon technique (doubleballoon enteroscopy or DBE). ...
Introduction:
Since 2001, device-assisted enteroscopy (DAE) has revolutionized the diagnostic and therapeutic capabilities for managing small bowel pathology. Though commonly performed, there have been no recent large studies to assess the use, yield, and risks of DAE and none that include all 3 DAE modalities. We hypothesized that DAE is safe with high diagnostic and therapeutic yields achieved within reasonable procedure duration and here we present a large retrospective multicenter US study evaluating the use, yield, and complications of DAE.
Methods:
After obtaining institutional review board approval, electronic records were used to identify all DAE's performed for luminal small bowel evaluation in adult patients at 4 US referral centers (Duke University Medical Center, New York University Langone Medical Center, Louisiana State University Health Sciences Center, and University of Massachusetts Medical Center) from January 1, 2014 to January 1, 2019. Electronic medical records were reviewed to collect and analyze a variety of procedure-related outcomes. Using the data pooled across centers, descriptive statistics were generated for the patient and procedure-related characteristics and outcomes; relationships between characteristics and outcomes were explored.
Results:
A total of 1787 DAE's were performed over this 5-year period (392 at Duke University Medical Center, 887 at Louisiana State University Health Sciences Center, 312 at New York University Langone Medical Center, and 195 at University of Massachusetts Medical Center). Of these, there were 1017 (57%) double-balloon, 391 (29%) single-balloon, and 378 (21%) spiral enteroscopies. The mean age of patients undergoing DAE was 66 years and 53% of examinations were performed on women; 18% of patients in the cohort underwent >1 DAE over this time span. A total of 53% of examinations were performed for suspected small bowel bleeding, 31% were directly guided by video capsule endoscopy findings and 8% were performed for abnormal imaging. A total of 85% of examinations used an antegrade approach and DAE took a mean of 45 minutes to complete; 76% of examinations revealed abnormal findings, with vascular, inflammatory, and neoplastic findings seen in 49%, 17%, and 15% of the cohort, respectively. Older age was significantly associated with any abnormal finding, including arteriovenous malformations (P<0.0001); 50% of examinations included a therapeutic maneuver, most commonly argon plasma coagulation/cautery (43%). There were complications in 16 examinations (0.9%) including 2 perforations (0.1%), 6 cases with bleeding (0.3%) and 1 episode of pancreatitis (0.1%).
Conclusions:
DAE is most commonly performed to evaluate suspected small bowel bleeding and is commonly directed by video capsule findings. DAE is safe, has a high diagnostic yield, with 76% of examinations showing abnormal findings, and frequently features therapeutic maneuvers. Advancing age is associated with abnormal findings on DAE.
... The lack of precise features in characterizing these lesions places a limitation on the accuracy of CE diagnosis. Therefore, Min et al. [18] in their retrospective study, evaluated the utility of an additional morphologic criterion, the mucosal protrusion angle (MPA), which was defined as the angle between a SB protruding lesion and its surrounding mucosa. The authors documented that MPA was a simple and useful tool for differentiating between intestinal true masses and non-significant bulges [18]. ...
... Therefore, Min et al. [18] in their retrospective study, evaluated the utility of an additional morphologic criterion, the mucosal protrusion angle (MPA), which was defined as the angle between a SB protruding lesion and its surrounding mucosa. The authors documented that MPA was a simple and useful tool for differentiating between intestinal true masses and non-significant bulges [18]. Their observation creates a useful extra tool for those who are faced with the question of 'mass or bulge?' SB microbiota alterations have also been implicated in the pathogenesis of surgical site infections (SSIs) and surgery-related complications (SRCs). ...
Over the last two decades, remarkable progress has been made in understanding the etiology and pathophysiology of diseases [...]
Small-bowel tumors represent a rare entity comprising 0.6% of all new cancer cases in the US, and only 3% of all gastrointestinal neoplasms. They are a heterogenous group of neoplasms comprising of about forty different histological subtypes with the most common being adenocarcinoma, neuroendocrine tumors, stromal tumors and lymphomas. Their incidence has been reportedly increasing over recent years, partly owing to the advances and developments in the diagnostic modalities. Small-bowel capsule endoscopy, device assisted enteroscopy and dedicated small-bowel cross-sectional imaging are complimentary tools, supplementing each other in the diagnostic process. Therapeutic management of small-bowel tumors largely depends on the histological type and staging at diagnosis. The aim of the present review article is to discuss relevant advances in the diagnosis and management of small-bowel tumors.
