I'm here to bring us back down to earth and use native intelligence to make some good decisions about how to manage small bowel disease. So I've no disclosures. My only disclosure is that I have a strong opinion that the gastroenterologist who performs capsule should perform deep enteroscopy rather than parcel out small bowel therapy and care. So that's my professional bias. So the way I think, I'm just going to stop with the indications, but I just want to take it to how, you know, you just start off and say, what is capsule good for and what does it not do well? Because that's going to tell me when I have an individual patient with a clinical problem, what's the best test for me to pick. So no one's going to argue that the capsule endoscopy is the best test for flat lesions, that it's not invasive, that it in under the best of circumstances examines the entire small bowel and that no question, it can very rapidly detect active bleeding, whether it's in the stomach, small bowel, colon, the caps, or even if you have an HHT patient swallowing blood, you'll see a nose bleed in the esophagus too. So it's very good to help immediately get us in the right place of where the bleeding's happening. But clearly you can't flush or distend and really look at lesion at areas carefully. There's no therapy, no tissue sampling, and I would argue localization at best is poor. And there's really no lesion sizing. It's not like radiology where you have a little scale bar and you can scale out the lumen diameter or the lesion diameter. There is no scale bar. It's eightfold magnified and it can look big or small depending on how close the camera is. So don't in a report say something is three centimeters or two centimeters. That's not possible. So how to improve capsule reading from my point of view is first you got to think like the small bowel. So it is long, people said anywhere from 300 to 800 centimeters. But the important part is, is that it sits on a mesenteric stalk and it's stuffed into this abdominal cavity. And so therefore there by definition is going to be a lot of sharp turns. Occasionally you'll see a straightaway with the capsule, but it goes around a lot of turns and just fold patterns. The jejunal folds are very thick. I call the ileo folds like a bald tire. It's spaces between and you can actually see the vascular pattern there. Then you have to think about small bowel motility. So the duodenum is the fastest in the West. It shoots that capsule through, whereas in the terminal ileum, where the IC valve sits, it's slow and it's slow because that's where you have to reabsorb bile salts and we need a lot of contact time to get all those bile salts efficiently taken up. This is the way I think of it. And so the capsule is going to sit there. And if you're constipated, have a lot of stool in the colon, it's going to sit there even longer. And then there's the to and fro motion that is going to shoot the capsule back and forth, but it also turns up bile, which is a detergent. So it turns it into this foamy atmosphere. And then on top of it, people may still be digesting some food from the day before. So there's a lot of places that you may not see the mucosa well. And lastly, it's a desert road. There's a few landmarks right when you get in at the pylorus, the sort of sign that says you won't get gas for the next 30 miles. But there's the pylorus and the ampulla and the duodenum, and then there's lymphoid hyperplasia and the terminal ileum or the IC valve, and then pretty much you're in the colon. So you don't have a good way of judging where you are. So how do you improve capsule reading? Well, you also have to think like a capsule. So there you've got the camera. It has a variable depth of view anyway from 156 degrees to maybe 360 with the four-camera version. And it magnifies eightfold. So little lesions can look pretty big that when you actually get to them with the deep enteroscope, they're pretty small. So you can't really judge that size very well. And it moves fast, again, in the duodenum and slow in the distal ileum. Now there's capsule systems that can now slow the frame collection down when the capsule's moving fast, and at the end of the small bowel when it's moving slow, it compresses everything because all those images are the same. And that helps you, but you have to know that your technology is doing that and it's not getting hung up at, say, a tumor or some sort of ulcerated area that it's trying to squeeze its way around. Then it hangs up and squeezes, as I said, around tight turns, and it tumbles two and four and around and around. And so you have to get used to this kind of way of looking at the bowel. So the next issue I have is what does a capsule miss? Because the minute the capsule doesn't show a lesion, you're not done. You don't say upper negative, lower negative, capsule negative, we're done. You say, uh-oh, what might have been missed? So certainly you have to know about the anatomy of that small bowel. If there's altered anatomy or even anastomosis sites, the capsule can roll around there and not really see it well. Jejunal and meccals you can sometimes pick up, but not always. Especially if they're thin-necked meccals, you may not see it. Isolated mass lesions, as people talked about before, 18% of the time it gets missed, and these are big cancers that get missed. Lesions in the edge of a frame, so it may be just one frame where it's sitting at the very edge, and that you'll miss. You'll go back and say, oh, there it was, but that's sort of in a retrospective scope. And then the duodenal lesions, as I said, the technology now is improved to sort of slow it there and help you to read better in that area. So what's the best way to improve capsule reading skills? Perform deep enteroscopy. This really allows you to make sense of what you were looking at when you read the capsule. It improves your learning curve enormously, and there's this great satisfaction of getting to a lesion you saw in capsule and actually treating it and taking care of the patient and being done with it and making all the decisions, because every individual gastroenterologist will have their opinion about whether to do something or not do something, and rightfully so because the complications are in the hand of whoever does the procedure. So everyone has their own take on what to do next. It's not that it's right or wrong. Some things are absolute, you're going to go one direction, but a lot of times it's people's opinions of how they think something should be managed. Okay, now I have this one called writing a quality capsule report. This is critical to guide management of whoever does the deep enteroscopy or just manages the patient in general. Sometimes there's a general gastroenterologist who refers for the capsule, and then the capsule person could make a decision not to go on and do deep enteroscopy or to go on and do deep enteroscopy, but there's a lot of banking on that capsule study. The quality of the study has to include transit, if it rapidly went through the bowel too quickly, or if there was a lot of debris or foamy stuff interfering with visualization. You have to say that in the capsule study. Transit time, mandatory to say when it first started traveling down the duodenum and the cecal images, when did it get there, and then you have to calculate what the small bowel transit time is. And if there's delays, you should put that there were delays in the stomach, maybe the person has delayed emptying and that's a clinical entity for them, and that may help in another dimension of their care. Or was there delay in the small bowel for unexplained reasons? Was it getting caught up where something might have been missed? A third lesion location, that's based on, first of all, saying, describing there's something there, an ulcer, a mass, a red spot, angiotasia, whatever you want to, whatever you find. But then you have to say it's in what percent of that small bowel transit time so that it's going to guide the approach to deep enteroscopy. And if you think the transit time is like nine hours and is just unwieldy in trying to predict really where that lesion is, you can go by fold pattern where you think it's jejunum because those folds look really plump or it looks really bald at the end where there's a vascular pattern. The only exception is in diabetics. You know, diabetics have a lot of glucagon effect and glucagon makes the small bowel very plump, causes intestinal hyperplasia. So some of the diabetics have these really thick fold patterns throughout their small bowel and it makes it kind of difficult to tell where that capsule is. And then, of course, lesion interpretation, not just what you describe, what you saw, but what you think it is. And that's given the clinical background of the patient. So it's lesion if it's an older person and it looks vascular, then of course it's vascular and that fits with their age and comorbidities. If it's a young patient and it's vascular, then you might be thinking more of some kind of congenital situation that this patient has versus the typical acquired ectasias in the bowel. And then this is my biggest plea to everyone out there in virtual world or wherever, save that video and the colored pictures and provide it to the deep enteroscopist. Because the problem here is, and it's worse now than it's ever been, no one is saving the video. And if they do, they have to be encrypted. So it's a big sort of pain to get that video over to the deep enteroscopist. And what comes over is a Xeroxed report that has black and white blurred out images. And this just makes it impossible when you send someone to a deep enteroscopist or they show up in the endoscopy unit to actually do the procedure, to try to make sense of what they're trying to find, look at, treat. It just makes it really difficult. So I make a plea, anyone who does one and has to send it to us, sometimes I refer people out and I send the capsule video with them so that the endoscopist who has to, or the person who has to then render yet another opinion, an expert opinion, they have all the information they need. So please save those videos. Now 30% of capsule findings are artifacts. And this is somewhat what discourages people from getting involved in deep enteroscopy because you spend a lot of time, it's a very ergodynamic procedure. You're sweating it out. And then you find there's really nothing there. And the question is, did it heal? Was it a vascular lesion that it healed or what's going on? So it can be very frustrating. So the best is to try to really not read artifacts as lesions or certainly call them potential or indefinite, or I'm not sure kind of lesions. So over to the left, reading AVMs as red spots as AVMs. Now no one can prove or disprove that bladder didn't bleed, but it's maybe at best a candidate lesion. On the bottom is the bubble. Of course, everyone's talked, don't read through an air bubble. It's certainly not a smooth fold that you call a polyp. Mass lesions. So pyloruses are frequently read as mass lesions. And the reason people get confused is because that capsule is rolling around in the bulb for an hour or even an hour or two hours. And someone thinks, wait a minute, two hours have gone by and that looks like small bowel lining and that must be a mass lesion somewhere. But in fact, if you look at that image in the left under mass lesions upper, you'll see that bumpy kind of texture that the bulb looks like, whether it's either Brenner gland hyperplasia or gastric metoplasia, the bulb looks very distinct when we look at it endoscopically and it's quite distinct in the capsule version as well. Below it is the ampulla. Of course, that's again, usually read as a mass when there's a big delay in transit in the duodenum. If someone thinks that's an adenoma or some sort of lesion. On the right is the protrusion, which I agree with the former speakers. This is the most difficult one to tell from a mass lesion and the one you worry about the most because you don't want to miss a small bowel tumor. And people talked about that before. The IC valve has been sent to me as a mass lesion. And here the tip off is you see the smooth lining, the so-called colonic smooth lining on the right. It's a big, huge lumen. And there you see the sort of viliform IC valve prolapse there in that image. And then the ulcers. Of course, people have read ulcers as when the lens presses against the bowel, it sort of whites it out. And that can be called an ulcer and mucus. You can see here there's mucus. Well, here, I don't really know. Do I really know? No. Standard endoscopy, we wash the mucus away to make sure there's not an ulcer under it. So here we don't have that capacity, but I don't see a red rim around it. I don't see depth that's kind of, I'm sensing that this is protruding out into the lumen more like it's mucus. Now is there help with these red spots and ulcers to give you more of a hint as to whether it's a real lesion or not? So the FICE options is sometimes helpful. There's articles written about the yellow-green setting where if it's sort of vague inflammation like an enteritis or some sort of injury from NSAIDs, you'd see this blue around the redness. And if it's a true ectasia, you'd see a red spot with green around it. And that makes you think more that this might be a vascular lesion than just nonspecific redness. On the right is using FICE to help distinguish an ulcer. Again, if you look at the upper left hand, you'll see that there's a sort of in the middle of very faint white kind of based lesion. But if you put on the FICE spectral lighting, you can see that there's a red rim in these different views. That may help you. So you're trying to get as close as possible to an accurate read on capsules. And lastly, Dr. Vamula Pali talked about the protrusion. I'm not going to go over that. She had a different scoring system. I think this one is easier for me to remember if there's bleeding, a mucosal break, and a regular surface look at the color and whether there's these white deformed villi, stretched villi, so to speak. And if there's more than four, it's probable. And you can see in the left here, there's a protrusion. On the right, these are submucosal, or we call them subepithelial now, lesions. And there on the bottom, it's irregular. You can see this prominent vascular pattern. It's big. How do I size this? You size it according to how much it fills the lumen. It's not a teeny thing, but it's not filling the entire lumen. So it's a reasonably sized lesion. How are you going to decrease these false positive capsule tests? The main thing we talked about, don't read it through an air bubble. Read your red spots when there's no characteristic features of a vascular lesion, meaning an irregular sort of slam dunk angioictasia. If it's punctate, read it as such. You can say no definitive lesion or red spot of unknown clinical significance. Or if you think it's the bleeding, it could be go after it and cauterize it. Recognize your pylorus, especially when the capsule is tumbling in the bulb. Really look carefully at a mass lesion and make sure that you're not in the bulb. Use technical tools such as FICE and these probable tumor scores to help you when there's a vascular lesion or an ulcer or a mass that's in doubt. So these are capsule facts. The others were artifacts. So in the left upper, you can see this sort of very standard angioictasia. I don't think any reader, we'd all be in agreement on this one. To the right, there's a white sort of center with redness around it. I think most would call this an ulcer. Most would call this on the sort of, I don't know if you can see my pointer here, but this looks like a very rounded. It's not smooth with the lining as Dr. Vamula Pali showed you. Here you can see two lumens. When you see two lumens, it might mean the capsule's going around a turn, but it might mean it's a Meckles. And this turned out to be a Meckles. This on the bottom with the big ulcer coming outside of this sort of what looks like a lumen, this patient was called Crohn's disease or diagnosed with Crohn's disease based on this one lesion in her small bowel treated with biologics and everything else. She presented with overt GI bleeding and she ultimately made her way to me and I did the deep enteroscopy and it was a Meckle diverticulum. Just to note about Crohn's disease, ulcers of Crohn's disease don't often bleed briskly like overt big bleeds. This woman had big bleeds requiring transfusion. That would be highly unusual for Crohn's disease to do that in a young person, much more likely a Meckle. Her Meckle scan was negative, but 40% of Meckles are negative in adults. You just have to really keep that clinical context in your view when you're trying to make decisions on what to do with lesions. Here you see blood coming out of a mass lesion. Again, it's on just one frame. This was one frame on the edge that showed the blood and then the lesion. And then there's a ulcerated stenosis. I'm moving now towards the left and this is the blue blab rubber nevus syndrome. This sort of congenital hemangiomas. Now I'm going to swing into some cases and the cases I'm going to talk about, I'm taking them all the way to decision-making and what we saw in the end to sort of help with the flow of what you do with capsule findings. This is a 26-year-old woman. She's 35 weeks pregnant and this is her second overt bleed with melanoma. First episode two years ago, it was unprovoked, had the EGD colon capsule Meckle, all were negative and the endoscopist decided to sit tight and do a CTA if she had re-bleeding. Well now she has re-bleeding, unfortunately now she's in her third trimester of pregnancy and she already received eight units of blood. She was transferred over and before she was transferred over though, I was reviewing her capsule study and from before, I was just reviewing the report actually because I didn't have the study and the study said there was green fluid obscuring the mucosa and the jejunum, otherwise a normal capsule. Now the outside referring doctor decided to do the capsule as the safest test for bleeding during pregnancy and it's hard to argue what were your other choices, go right to deep enteroscopy or do a imaging study and the decision was made to go with capsule. I think that was a reasonably good decision. So here's the capsule now. This is the second capsule study and now you can see the capsules going. See that big bubble and how smooth the lining is behind the bubble? So be careful. And there on the edge, if you saw, there was a little edge. You might have caught it with your eye, but here's a lesion that looks like it's going to be a subepithelial mass lesion and it's kind of bouncing back and forth. I don't know if I can look once more and see if you can see that edge coming into view out of the bubble in the right lower. See that little white plaque? That actually turned out to be the ulcer of this lesion. So just a word about these mass lesions, you have to make a decision. Do I want to go in and recommend it be marked for, and you don't even need to necessarily biopsy it, but mark it for the surgeon to do minimally invasive laparoscopic surgery? Or what we see is in the lumen, what's on the other side here? Is this a big, huge mass that any surgeon is going to be able to see. They don't need me to go in and mark it. And it's kind of hard sometimes because what you don't know is what's on the other side of these mass lesions and where they're arising from. So in this case, it looked pretty big. The woman was pregnant. Here's her lesion, and you can see the red blood vessels and irregular. And so we decided with OB-GYN to give her steroid injections and to mature the fetal lung and induce delivery first and then take out the tumor. And the question was, how were we going to get at it? And we decided to go with the laparoscopic approach. And then I would be in the operating room to do a deep enteroscopy if somehow the surgeon couldn't find where this lesion was. So we were all kind of on standby. She went through the delivery fine, and then she went to the OR. And this just shows you kind of the other side, what the surgeons see. And there's this huge vascular gist in the end, lesion. And you can see how vascular it is and how dangerous it would be to let this sit waiting to bleed again. So that's the decision we made. We could have sat and waited for her to go into natural delivery, but as you know, blood volume goes up. There's a lot of pressure with vaginal delivery, and we were a little bit afraid of getting into some sort of harmful situation for the mother. So here's the tumor, and here the ulcer bed was that little edge you saw in the capsule. This was that white ulcer bed that actually bled into the lumen. And then of course, this is the pathology, and it was CKIT positive and a gist tumor, and it was resected, and mother and baby were fine. So what are the case points here? The biggest is this missed lesion on capsule endoscopy. Be very careful that you've looked at the quality of that study, and you're really convinced that that was nothing there. But even if you are convinced, in a young person with an unprovoked overt bleed, you have to suspect a tumor or an ulcer or some lesion that you're going to find. So you really have to do a complete small bowel examination, and that means a CT or MR, and usually I do a triple phase CTE because I want to pick up some smaller vascular lesions if it's not a tumor or an ulcer. So just be aware that upper lower capsule is not the end of the story, particularly in young people or older people who you have a high suspicion. The gist tumor is a highly vascular tumor. In fact, some people say don't even biopsy it. If you're going to mark something that you think is a gist tumor, just mark it because it's really vascular and they can bleed massively. So just be careful of those tumors even when you're sampling. Okay, here's a case. 69-year-old man. He has myasthenia gravis. He had obesity and had a Roux-en-Y gastric bypass. He's then had a PE, and he's on a Bixopan. So he had a GI bleed with melanoma requiring a transfusion. He had the upper and the colon, and there was no source. So before you say upper lower capsule, you say, well, wait a minute. What is the differential? What's the most likely place that this person is bleeding from with melanoma, an upper source we're thinking? So in a Roux-en-Y or any kind of altered anatomy, your first question is, is there an ulcer at that first jejunal-jejunal connection site, which is not seen. It's usually in the Roux-en-Y bypass. It's 100 centimeters or so down, and a gastroscope virtually never reaches there. A pushmate, but not a gastroscope. So there could be an ulcer there. Secondly, he could have planopeptic disease of the duodenum or ulcers in the stomach, or he could have a gastric cancer in the excluded stomach given his age. So the question is, what's going to give you the money to get to the answer to treat and do what you need to do? If you put a capsule down, again, I don't know if you can see my little arrow, but it goes down the esophagus. It goes down the efferent limb, and it never goes up that afferent limb, and you don't see that connection site well. So I would argue against a capsule and maybe, in my view, to go right to a deep enteroscopy first, and then maybe a capsule after that if you don't find something. So the question is, capsule, do you do a CT, MRE, or do you do a device assist? And I tried to get this. The outside referrer did a capsule. I tried to get it. I couldn't even get it, but basically it was read as normal. So here's the deep enteroscopy. So I'll show you this. I use the double balloon system, and I'm going down, and there you see the two limbs, and you got to pick one. So sometimes you see the foamy bile coming, and you get the right limb. Sometimes you don't. I didn't get the right limb, so I quickly injected it so I didn't go down it again. And now I'm going into the other limb, which is the biliary limb, and I'm going up, up, up, and there I am in the duodenum, and there's the ulcers, and there's the bleeding source. No visible vessel, some flat pigmented spots, and here is, that was the pylorus you were just looking at, and I think I got into the, that's the excluded stomach. It always looks very atrophic because there's no food that the stomach seeds, so it looks very atrophic. So for me, that would have been the next best test for this RU-Y patient, not the capsule, but you know, sometimes you pick one way, you're wrong, you go the other way, so I'm open to that as well. This case, 89-year-old woman, first overt GI bleed, so she's 89, she had melana, she's got AFib, had a Watchman, now is off anticoagulation, but she had a bleed anyway. Her outside upper and lower, so sure, no bleeding source, and then she had ongoing melanin, was transferred to us, and here, the team, the GI team decided to repeat the upper endoscopy, and if they didn't find a bleeding source, they were going to put the capsule down endoscopically. Now, would you have done a push enteroscopy versus an EGD to really kind of get to that early part? I might have done that rather than just another EGD, but again, people will choose what they're going to choose, but I would have probably gone with the push, and then, if not, still put the capsule down. And so, here is how you can tell this is endoscopically placed versus swallowed, because you see this big white rim of the capsule holder, and it's looking and trying to get into that duodenum where it gets deployed, and that was fine, except for an hour plus that capsule sat rolling around in the pylorus and round and round and round. So, the first thing was the percent transit time in the bowel was a little off because the endoscopist read this as the first duodenal lesion versus when it started moving down the duodenum, but either way, at one point, as the capsule was coming around, this is what it runs into. Now, that, to me, is a big red fresh clot, and there's some blood sort of oozing around it, but there's no underlying lesion, right? It's a clot. You don't see anything else but a clot, and then the rest is blood, and of course, here is the end of the study. There's old blood, and there's some lymphoid hyperplasia, and now it's in the colon. How do you know? Well, you saw the lymphoid hyperplasia, and that looks like colon. Okay, so what's your impression on your capsule read here? Oh, I gave the answer down there, but here, it's small bowel bleeding, active small bowel bleeding without an underlying lesion. That's how you call it, and then you say the lesion was, they said, within 30%, but it was probably higher than that of small bowel transit time, and it's likely vascular, given her age and her cardiac history. So, here's the upper double balloon that was formed. I'm sorry, I didn't have a video. It kind of glitched. I'm very sad, because this would have been a good video, but here you see the lesion. It's sort of a weird lesion, right? It's a bulge, and then there's blood coming out the tip, and it's red blood, so this is clearly the bleeding lesion, and the question is what is it, and we're stuck with this. You're deep in the small bowel. What do you do with this lesion? Do you burn it? Do you put a clip on it? Do you do what? Well, I can tell you just even manipulating around it made it bleed more, and so what I did in these kinds of situations, you want to definitely know where that lesion is, your surgeon, because if you're not right, then either IR or surgeon has to get in there and try to stop it. She's 89, so the first thing I did was marked it with two tattoos on both sides, and then the second thing I decided to do was put clips on, and when I put clips on, this bulge kind of decompressed it. Well, first I touched it to see if it was a hard mass, and it was soft, so then I put clips on, and that was what I did. Now, what was interesting is on the way out, we saw on the way in and the way out, we saw this other lesion that the capsule missed, which looks kind of bumpy with these dilated lymphatics here, and so in my opinion, I've seen this before. I thought this looked to me like a lymphoma, so we took pictures, and that's in fact what she has is a follicular small bowel lymphoma. Whether this bleeding lesion is involved or not, I don't know. We'll find out because this is a very recent case I had. Okay, a word about vascular lesions and the way you read them, whether you read them with deep enteroscopy or you read them on a capsule, it's kind of the same. This is the Japanese classification system, but I think we talked about this. What I want to point out is not the obvious angioictasias, but on the bottom here, these two lesions of little punctate red spots, the one on the left is kind of a low risk punctate teeny little lesion, less than a millimeter. This is by deep enteroscopy assessment, but the one on the right is equally small, but you can see blood trickling down, so that's a lesion you certainly would treat. These punctate lesions are tough. No one quite knows what to do with them, but you do the best you can. Then there's of course the higher flow lesions, the so-called AVMs or the streaming lesions or these pulsatile raised dulafoil type lesions. Here, if you're going to treat them, the bi-cap is not so helpful. You need a bipolar. You're deep in the bowel. You got to wash and quickly find where it's filling in and then burn that spot, or if it's pulsatile like this, you can put a clip on, trying to put the clip down so you can see what the pattern of the vessel flow into that site is, which is its own art altogether. Here's another case, 82-year-old woman. She's a big-time smoker, still smoking two packs a day, has AFib. She's not on anticoagulation, has chronic GI bleeding. Her capsule showed non- bleeding angioictasias, and here she had, before she came to me, two courses of thermal therapy. The last one, recently, they treated 67 angioictasial lesions, and now she's got ongoing transfusion requirements. She's on octreotide and still requiring blood transfusion and referred with her recent capsule study for further decision making. Okay, here I have the four-camera version of the capsule. I was able to find this one, and here's what was sent to me. You can see right off the bat that there's vascular lesions. You can see you're looking at a strip. It's not a lumen, and that's a little odd to the eye of the endoscopist. We're used to seeing lumens, but when you compare the four-camera to the single-camera, the diagnostic yield is the same. It's fine to read this, and it's just as good. It's just a little odder to look at when you're used to looking at a lumen, but here you still saw a lot of lesions. This is proximal, and as I looked at the distal end of this, you can see the folds are not quite as big, and there really aren't any vascular lesions, so these are likely acquired up high in the jejunum. And the question is, why does she have so many? This makes you start thinking about HHT or some sort of variant of HHT, but the important part in this top, I'll run it again, is there's no active bleeding from any of these, so which do you want to pick to treat? I don't know. Do you want to treat 67 again, or do you want to just say, I don't think we should burn these anymore? And she's still smoking, so smoking is going to drive the bad blood flow to the bowel. So she's, in my view, failed thermal therapy in the past, and I would only treat this kind of patient if she had active bleeding. Would I look for a genetic or HHT variant? No nosebleeds. She didn't have any other AVMs in her body, so I don't know if this is a variant. Could tell her to stop smoking. It may not make a difference at this point. And here, maybe you could consider thalidomide or low dose Avastin if they have HHT, but I just want to point out to you, in HHT, the latest recommendations are not to treat GI lesions unless they're actively bleeding. In other words, only 30% of HHT patients actually have GI bleeding. Most is nose bleeding. It doesn't matter how bad the nose bleeding is, it's still nose bleeding. So be careful about treating these because they don't get better and it's not going to help the patient. All right, what do I have here? I'm getting to the end here. This one I'm going to skip because this is just another example of a rolling capsule in the bulb. Oh, except for one thing, this was a capsule done for iron deficiency anemia. And the point is well made that there's a very low diagnostic yield if you have not shown that there's either occult bleeding by fit testing or overt bleeding by clinical presentation. That is an important point. We do a lot of capsules for iron deficiency anemia, and when I look in the charts, there are no stool hemocult, not forget hemocult testing, there's no stool fit testing to show that this is an ongoing or even ever was bleeding from the GI tract. So let's try to do that. Now in ulcerating disease, that was already pointed out, the biggest thing is to be very careful about asking about GI abdominal symptoms, gas, bloating, abdominal pain, weight loss, any change in digestion where your patient says, gee, I used to eat fine and now I'm having this bloating indigestion when I eat. Be careful, that may be an obstructive symptom. So they can have overt or occult bleeding and you just want to be careful because don't think all capsules can be retrieved when they're deep in the bowel, we oftentimes can't get them. So here's just a few capsules. When you see debris on a capsule like this that's sitting in a pool and you're in the small bowel, you should be very watchful for a stenosing lesion and there it is. The same down here, you run into a pool of debris that's just sitting there, the capsules rolling around in it. You're not in the colon here, you're in the small bowel and eventually if you look long enough and you're lucky, some edge of an ulcer there on the left will come through. This is more of an NSAID type ulcer. See that? And this on the bottom is a white diaphragm coming up. Right there, you saw it sort of blanch out like that. So these are NSAID more and this is just a case I'm going to skip. So going on to some real-world capsule reading, I'm just going to go through a few of these. Here you see that one moment in angiotasia, one moment. The rest is debris, one moment. You got to be watching with your eyes. Here there's an ulcer. I think it looks ulcerated or is this just mucus? I think this is ulcer. Here this is a weird mass lesion with this little umbilicated thing on top of it. I have no idea. I think this is a smooth muscle ulcer. Here this is a Putzjeger polyposis patient. You can see that here there's these small little jits of polyps but nothing big. And here you see this prominent vein. This is the same patient. Now the capsule's squeezing around here trying to get through and is that a polyp? I can't tell because the capsule squeezes through. So in Putzjeger polyposis, I tend to get imaging because I like to know size. If it's less than a centimeter, I don't take it out and I like to know location so I know where I have to go to get it. I think what's this one? I don't even remember some of these I put up here. Oh yeah, that was blood in the corner just for a minute. And this again is a splayed area. You see how the blood vessels splayed and see that mass sort of sticking out? And that you would be able to call a mass. Here are some others. This going along here. You know what was here? Again an ulcer but maybe it's a meckle because look at that ulcer. There's a lumen there, right? Another lumen. So that might be a meckles, an ulcer coming out of a meckles lumen. I don't know what this is. This may be too long. Oh, this is popping through the pylorus. This is rolling around in the pylorus. See, there's the pylorus and there it's rolling around. So recognize that pylorus. And oops, where did I go? I don't know. The other on the right, that's celiac. Dr. Harris covered that. And here's the meckle with this was a meckle with this is a prolapsed meckle. See, there's a little mass lesion in that meckle. That's a prolapsed meckle. If you go up with a lower double balloon, don't remove that like a polyp because you'll have a perforation. And then this is, well, what is this? Oh, this is also a prolapsed meckle. This is that same meckle when I went for lower deep enteroscopy, it's prolapsing at my lens. So that was a prolapsed meckle and that gentleman went to surgery. So my take-home points for capsule endoscopy, accurate reading as Dr. Cave started out with requires skill in upper endoscopy and lower endoscopy to start and push and then onto reading capsules. And you have to understand the behavior of the small bowel and the capsule. There's a high percent of false positive findings. This costs a lot of money and a lot of sweat equity of the deep enteroscopists. So the skill of the reader is key and the knowledge that we can't wash debris and bubbles and mucus and we're going to read these false positives. When equivocal lesions, try the FICE and the probable tumor scoring, be aware of capsule studies and known Crohn's disease. Remember, even if their edema and inflammation gets better, their wall is still stiff and the capsule is a stiff object. It's not a piece of steak or meat where it can compress and get through these areas. It's a rigid structure. If there's a mass lesion, in my view, I like to have CT imaging for both sizing, localization to see if I have to mark it or send it right to surgery. And if there's multiples, you might think of a carcinoid tumor and that tips you off into a diagnosis. In young bleeders, remember upper lower capsule is not enough. They need the whole nine yards to figure out why they're bleeding. And the best, it might be a dulafoil in the end and that you can't find unless it absolutely bleeds or a congenital lesion. And then you're kind of stuck, but at least you've done everything you can to make sure it's not a tumor or an ulcer. Best way to improve capsule reading is to perform deep enteroscopy. I hope more people do it who read capsules. I don't view deep enteroscopy as an advanced interventional procedure. I view it as an extension of push enteroscopy, which we all do. So I hope everyone takes it up. Okay, I'm done.

small bowel disease

capsule endoscopy

deep enteroscopy

gastroenterologist

non-invasive

lesion detection

clinical context

patient management