Welcome to our ASGE training video on video capsule endoscopy. I am Dr. Christopher Marshall, and I'm here with Dr. David Cave and Dr. Anupam Singh as we discuss video capsule endoscopy, covering everything from preparation to reading. In this segment, we are going to introduce you to the basics of video capsule endoscopy. We will discuss the hardware and how patients are prepared. We also discuss some of the indications for capsule endoscopy. We will also discuss some of the absolute and relative contraindications to the procedure. We will then review common features to the various capsule systems and discuss approaches to how videos are read. Let us begin by discussing the capsule hardware. The capsule was first approved for use in the United States in 2001 and quickly became the first line test for small bowel diseases by 2003. The capsule itself measures approximately one centimeter by two and a half centimeters and can be deployed in patients, including children as young as two years of age. Depending on the manufacturer, the field of view ranges from 145 degrees to 170 degrees and takes anywhere from two to three images per second over an approximate eight-hour time frame. Images are transmitted wirelessly to an external recorder where the video is downloaded and reviewed. Some systems include a real-time viewer where live images can be viewed directly on the recorder. Let's now review the common indications for video capsule endoscopy with the understanding that indications suitable for reimbursement will vary between payers. One of the most common indications for capsule endoscopy is suspected small bowel bleeding. The second most common indication is for the diagnosis of suspected small bowel Crohn's disease, typically in a patient with abdominal pain and diarrhea. There are other indications besides this, including evaluation of a suspected small bowel tumor or even abnormal small bowel imaging. Video capsule endoscopy can be used for surveillance in patients with inherited polyposis syndrome, such as Putz-Jegers disease. The capsule is also helpful in the setting of drug-induced bowel injury, as occurs with NSAIDs. Finally, capsule can be used in patients with refractory or partially responsive celiac disease to exclude ongoing inflammation or to exclude ulcerative jejunitis and lymphoma. When consenting patients for capsule endoscopy, one must be sure to discuss a few complications that are specific to capsule endoscopy, including capsule retention and small bowel obstruction. Capsule retention is where the capsule is held up in the small bowel, either due to hypomotility or a lesion. This is reported to occur in up to 1% of patients with gastrointestinal bleeding and up to 13% of patients with Crohn's disease. Small bowel obstruction due to retention is much less common. Other things that should be mentioned when consenting patients would be failed image capture due to capsule malfunction or for the leads coming off of the patient. There are only a few absolute contraindications. Placing a capsule during an ongoing bowel obstruction would result in capsule retention and potential worsening of symptoms. Performing an MRI may result in injury as well. The other contraindications are relative. Small bowel obstruction is a relative contraindication, but the capsule in this scenario can actually be used to diagnose the area of the abdominality. Since the capsule would not be able to pass this point, it will sit in the area of the abdominality and make it easier for the surgeon to target the area of interest. Demented patients may not be able to swallow the capsule, as would patients with dysphagia or even a Zanker's diverticulum. These issues can often be overcome with the use of a deployment device. It should be noted that caution should be used in inoperable patients, as there is a slight chance that there could be a complication requiring surgery. Finally, pregnancy and pacemakers are listed as relative contraindications. But to our knowledge, there have been no serious adverse events for use in these populations. The Patency Capsule is an option for use in patients at risk for an obstruction. It can be considered in patients with obstructive symptoms, heavy end-steroidal use, known strictures, or abdominal radiation. The device is the same size as a standard capsule and is composed of lactose and barium that can be seen on an X-ray or with an RFID detection device at approximately 30 hours after ingestion to determine its presence. If the device is passed or is located in the colon, then it's considered safe to perform the capsule endoscopy. In patients with gastroparesis or delayed intestinal motility, endoscopic placement with this device will allow deployment into the small bowel directly. The capsule slides into this holder, and then the technician could deploy the capsule similar to opening and closing a net or a snare. There is much variability in the recommendations for preparation of patients who undergo video capsule endoscopy. All patients should have an overnight fast. Some institutions recommend PEG-based bowel preps. Others use simethicone to decrease bubbles, while others use prokinetics to help move the capsule through the GI tract. It is our practice, though, not to use any additional prep besides fasting alone, as we feel it decreases the patient's tolerance of the procedure and willingness to have it repeated if needed. There are several companies who manufacture capsule devices and software. While they all have specific nuances, they all tend to share common features, such as landmark capture and thumbnail capture. They all typically have a forward, pause, and reverse button, an ability to perform a quick review, and software to detect suspected blood. I would like to quickly demonstrate some of these features. You see here there is a time bar. This is the running time of the capsule endoscope. The images below the time bar are thumbnails that have been captured. This software uses color coding on the time bar to help you visualize whether the location represents the stomach, the small bowel, which in this picture is brown, or the colon, in this picture is green. This is an example of the play, pause, and reverse buttons. This is very helpful if you wish to rewind or move forward a few frames to review an area of interest. Another feature of the software is to provide different viewing options, either single view, where there is only one image on the screen, dual view, where there are two images, quad view, where there are four images, or mosaic view, which has multiple images. This all depends on the provider's comfort level on how many images they wish displayed on the screen at a time. Most providers are comfortable with using either quad view or dual view. In our practice, though, we prefer to use quad view as this maximizes the amount of time the individual images remain on the screen and maximize our ability to detect pathology. This screenshot is an example of what quad view would look like in a capsule study. We instruct our trainees to stare at the center of the four images and stop playback if any abnormalities are seen. As alluded to before, the software also allows marking of individual thumbnails and then the ability to label individual thumbnails for review at a later date. This can be accomplished by clicking on the specific button in the program, such as the plus button that you see here in my screenshot. In this software, you can also accomplish this by using a right mouse click, and then you can choose whether this is the landmark of a gastric image, a duodenal image, or an individual thumbnail of interest. As we discussed previously, the suspected blood indicator is a very useful tool in cases of suspected GI bleeding. The arrow is pointing out the area the computer software has detected images of blood. When you review the images, you can see that the area it has identified clearly represents blood. While this feature is very helpful, it should not substitute actual review, as it is very much subject to artifact. Ultimately, there is no defined approach to reading capsules, and providers will have to find what is most comfortable for them. In general, we typically perform a quick review to find and mark the most important landmarks, which will include the first duodenal image as well as the first CEQL image. The video can then be rewound back to the beginning, and we can review more in detail from the first duodenal image to the CEQL, and review this in depth. Some providers prefer to read in quad view over dual view, as the images remain on the screen longer. There is also much variability at the image speed at which people read capsule endoscopy, but the speed should be set at a minimum of what it takes for the provider to find all relevant pathology. This section of the video provides an opportunity to review the normal anatomy and the variations seen on capsule endoscopy. The normal variants can be quite wide ranging, and may be a source of confusion to those early on the learning curve. Capsule endoscopy can be regarded as physiological endoscopy. There is no control of the movement of the capsule, and no inflation of the intestines. The capsule is moved by peristaltic activity of the intestine. This means it can move backwards, forwards, and tumble. It can be extremely difficult to tell which direction the capsule is pointing. The magnification of the device is such that it can resolve individual villi, which, if there is fluid in the lumen, can be easily seen. If there is only gas, then they will flatten out and can no longer be seen. When ingesting the capsule, the teeth may be visualized during the process of swallowing, and in this slide the papillae on the tongue are also seen. Very occasionally, the capsule can be aspirated into the trachea, and the vocal cords may be seen, or even the carina. The patient will usually cough the capsule up, and assuming that this happens, the capsule should be then delivered endoscopically, so the process of aspiration does not get repeated. Transit of the capsule through the esophagus is very rapid. The z-line may be clearly visualized or not seen at all. Transit through the esophagus prolonged for more than 30 seconds raises the possibility of a motility disorder. The gastric folds are usually seen clearly, particularly in the antrum. The fundus is poorly seen or not seen at all. This is an example of a pancreatic rest, or heterotypic pancreatic tissue. This is similar to the view seen through a conventional endoscope. As the capsule passes through the pylorus, it tends to blanch the microvasculature of the pre-pyloric area, due to pressure exerted on the mucosa by the capsule driven by gastric peristalsis. This is a useful tip that demonstrates that the capsule is about to pass through the pylorus. Sometimes the capsule would pass through the pylorus pointing backwards, so the distal side of the pylorus is seen. Occasionally, this side of the pylorus may be inflamed and erroneously interpreted as a stricture. This misinterpretation is prone to occur when the capsule moves deep into the duodenum and then moves backwards into the duodenal bulb. The ampulla of vata is seen only about 5% of the time that a video capsule passes through the second part of the duodenum. This is in part due to the very rapid transit time of a capsule through the duodenal sweep. The ampulla should not be mistaken for a polyp. Having said that, if the capsule endoscopy is being performed for patients with apoliposis syndrome, an adenoma may be detected in the peri-ampullary region. Intestinal villi vary very substantially in appearance, but remain within the normal range. They may appear thin and discrete structures. They may also appear matted, but they should be uniform in shape. In terms of colour, they may be almost translucent or white. White villi tend to appear as isolated dots when individual villi are full of chyle. This is a normal variation. The appearance of normal small intestinal folds is quite variable. The image on the right is seen where there is little or no fluid or gas in the lumen and reflects pressure from the capsule on the microvasculature as peristalsis pushes it through the intestine. The image on the left is similar, but there is some intestinal fluid. Bubbles in the lumen of the small intestine are a frequent cause of diagnostic confusion. If it is at all possible, avoid any interpretation of a lesion seen through a bubble. All sorts of false colours and shapes can be seen because of the presence of a bubble. This is particularly true of blood vessels and angioectasia. Large intraluminal bubbles tend to flatten out the villi. Deposits of cholesterol are frequently seen within the mucosa. This variant is more common in older people and has no pathological consequences. Its presence can be confirmed by seeing blood vessels running across the surface of the plaque. The deposits of cholesterol can be quite pleomorphic. They can occur as plaques, large or small, or even as polypoid structures. Lymphectasia is a common finding. It is usually a small polypoid or flat structure that is bright white or yellow and is comprised of villi distended with chyle. Lymphoid hyperplasia is a common finding in the distal ilium of young people. It may occur at any age and can consist of a single lesion or multiple lesions which appear like small polyps. These are a physiological variant and require no treatment. Submucosal lesions and extraluminal indentations can be very hard to distinguish. Extraluminal impressions tend to be flatter. The angle between the indentation and the luminal surface is greater than 90 degrees. The mucosa should not be stretched or ulcerated. Submucosal lesions tend to have a less than 90 degree angle between the lesion and the mucosa. The mucosa is often stretched, so there are no folds over the lesion and there may be ulceration or umbilication. If the lesion cannot be resolved as to its nature, then this is an appropriate use of CT or MR enterography or deep enteroscopy. Blood vessels tend to have a constant calibre and are easily distinguished from angioectasia. Flea bactasia or dilated veins are a common phenomena. They represent distended venous structures and unless they are very large when they become ectopic varices, they do not bleed. Intraluminal debris is a common finding. The panel on the left shows some vegetable matter. The upper right panel shows pill fragments and the lower panel shows one capsule visualizing another. In this segment, we're going to discuss the role of capsule endoscopy in small bowel bleeding. The video capsule is a useful tool for small bowel bleeding. It is indicated in cases of overt bleeding where either blood or melanin is seen or in occult bleeding where the patient may have iron deficiency anemia or occult blood in the stool. Besides making the diagnosis of bleeding, it is also a helpful tool to help localize the bleed and then based upon this localization, a decision about endoscopy, enteroscopy or colonoscopy can be made. When the diagnosis of gastrointestinal bleeding and capsule endoscopy is relatively straightforward, localization can be difficult. Typical features of bleeding include plumes of blood, blood clots and melanin. It is important to recognize many things can bleed in the GI tract. In younger patients, we generally think of IBD, dulafoil lesions, a meccal diverticulum and tumors. In older patients, we think about angioictasias, erosions and NSAID enteropathy. With this said, there is considerable overlap and we have certainly seen older patients with tumors, IBD and dulafoil lesions. In the proper clinical setting, you can see small bowel varices or even an aortoenteric fistula. This is an example of bleeding without a clear source. The video starts with normal small bowel mucosa. There are bubbles and bilious material. This is followed by a plume of blood which then enters the lumen. This video is an example of more proximal bleeding viewed distally. In this video of the jejunum, there is bleeding that originates in the duodenum. You can appreciate that the material in the bowel appears much darker, almost melanic. You then catch a view of a clot which is transverse down the small bowel, originating more proximally. It turns out that timing is important when performing video capsule endoscopy. In a retrospective study we published in Gastrointestinal Endoscopy, we found that in cases where the video capsule endoscopy was swallowed within three days of admission for bleeding, the yield of finding active bleeding or an angioictasia is much higher than when the capsule was done after three days or as an outpatient. Angioictasias are superficial ectatic blood vessels with a thin wall that are prone to bleeding. They may or may not have an endothelial lining and may or may not have a venous component. For that reason, angioictasia is the most correct term, not arterial venous malformation or AVM as they are commonly referred to. Some physicians may refer to them as simple vascular lesions, angiomas, venous ectasia, or even angio dysplasia. Angioictasias are one of the most common lesions to cause bleeding in the small intestine. Their incidence increases with age and are seen in settings of other diseases, such as aortic stenosis. Typical features of an angioictasia are that they are flat or have a slightly raised surface, are uniformly red in color, and have well-circumscribed fern-like or stellite margins. In this video, you see normal appearing duodenal mucosa followed by an angioictasia that comes into view. A deep enteroscopy was subsequently performed on this patient. The angioictasia was found and cauterized using argon plasma coagulation. As I mentioned earlier, the diagnosis of bleeding is typically straightforward, while it's the localization that can be difficult. In the proximal small bowel, you may see bleeding proximally followed by melanic material and a clot distally, as seen in the earlier video. Bleeding in the distal small bowel is usually preceded by normal bilious material followed by a clot or a plume of blood. Bleeding in the colon can also be detected in the capsule as well. Usually you'll see normal bilious material throughout the small bowel and blood as soon as the capsule enters the cecum, or you may see normal stool in the cecum that begins to mix with blood. On the left hand of the screen, blood is clearly seen in the duodenum. As the capsule moves through the small intestine, the blood becomes more melanic, and by the time it reaches the cecum, there is obvious melanoma. This is a young patient of ours with obscure bleeding. As you can see, there is normal bilious material in the small intestine. As the capsule enters the cecum, though, there is fresh blood. This is highly suggestive of a cecal bleed. In other cases, the capsule enters the cecum with normal appearing stool, which then begins to mix with blood. This again suggests bleeding in the cecum. This is a representative image from the previous video. You can appreciate in this photo normal appearing stool mixing with blood. Intermittent small bowel bleeding is one clinical scenario that warrants extra discussion, as it has implications on how we approach the patient, either anterograde, retrograde, or surgically. In a typical case, there is bleeding proximally that starts and stops intermittently. This results in a pattern where there is evidence of blood, followed by bilious material, followed by blood, and so on. This is important to recognize because there is typically only one proximal source of the bleeding, and this pattern does not represent multiple individual lesions in the small bowel. This is a screenshot and video of this scenario. As you can see, there is a plume of blood in the proximal small intestine. This is followed by bilious material, which is then followed by more melanic material and blood clot. If we look at the time bar, the red indicator represents blood detected by the software. When looking at the blood indicator alone, you can appreciate the intermittent nature of the bleeding. The blood detector is detecting intermittent blood being carried down the small bowel and not individual lesions. This is an algorithm on how to approach small bowel bleeding, adapted from the 2015 Clinical Practice Guidelines published by the American College of Gastroenterology. The left side of the screen should be followed when approaching a patient with brisk small bowel bleeding. In this scenario, it may be too dangerous to delay intervention by waiting for the time required to perform a capsule endoscopy. If the patient is hemodynamically stable, you can obtain a bleeding scan or CT angiogram with the plan of going to angiogram with possible embolization if these are positive. If the bleeding scan, angiogram, or CT angiogram are negative, then we would consider enteroscopy. In the clinically unstable patient with a high suspicion for small bowel bleeding, it is reasonable to go directly to interventional radiology for an angiogram. This scenario contrasts those that fall into the category of subacute ongoing bleeding. In these patients, we would recommend capsule endoscopy, if available as an inpatient, or CT enterography as a second-line test to start with. If these are positive, we would proceed with deep enteroscopy and apply therapy if the source is found. If the capsule or CT enterography is negative, we often repeat the procedure. capsule at the time of active bleeding to increase the chance of finding the source of bleeding. Depending on the patient's history, it would also be reasonable to consider a bleeding scan, angiogram, or even interoperative enteroscopy. In summary, angioictasias are the most common lesions seen in small bowel bleeding in patients over the age of 40. Video capsule endoscopy, when used early in gastrointestinal bleeding, has good diagnostic and localization value. While helpful to diagnose small bowel bleeding, it can also be useful to diagnose colonic bleeding. Remember that intermittent small bowel bleeding may be mischaracterized as multiple lesions and warrants close attention. The objective of this presentation is to discuss the etiology and pathogenesis of different ulcers and strictures that are noted on video capsule endoscopy. Ulcerations of the small bowel can occur due to inflammatory etiologies or medications. Amongst inflammatory etiology, Crohn's disease of the small bowel is the most common. Other inflammatory etiologies include Bassett's disease, advanced stages of celiac disease presenting as ulcerative jejunitis, or the rarer but increasingly recognized entity called cryptogenic multifocal ulcerous stenosing enteritis. Amongst medications, NSAIDs are the most common etiology of causing a variety of small bowel pathology. Slow-release potassium, chemotherapeutic agents, and some antibiotics have also been implicated as possible causes of ulcers. Rarer etiologies include a variety of vasculitides such as Henoch-Schonlein purpura, systemic lupus erythematosus, and polyarteritis nodosa. Radiation entropathy should be kept in mind in patients with prior exposure to radiation therapy. Ischemic and infectious ulcerations are not seen commonly. Crohn's disease can affect the small intestine in up to 70% of the patients. And of those, up to 30% of the patients have disease limited to the small bowel only, particularly the distal ilium. Currently, there is no gold standard for diagnosis. NSAIDs are in the differential, and a history of NSAID use should be taken in all patients. Primary drawback is relative contraindication in patients with known or suspected strictures. However, patency capsule can be used in such cases. A wide spectrum of findings are noted on capsule endoscopy in patients with Crohn's disease. Minor findings include focal Willis denatation, athoid ulcers, Willis edema, mucosal nodularity, and cobblestone. Findings in advanced stages of the disease include serpigenous, stellate, or linear ulcerations. These can confine together in advanced stages to cause circumferential ulcers. In patients with a stricturing variant of Crohn's disease, ulcerations are associated with luminal strictures. Here is an example of a patient with Crohn's disease with diffuse Willis edema. As the video advances, focal areas of Willis denatation are noted. Focal areas of Willis denatation surrounded by edematous villi is highlighted in this still image. This video clip shows an aftus ulceration, which is characterized by a central yellow spot surrounded by a red ring. This characteristic finding of a central yellow spot surrounded by a red ring is noted in this still image. Crohn's disease is characterized by transmural inflammation, which can cause deep ulcerations. This video clip shows this characteristic finding of a deep ulcer. Here we see a still image depicting the deep ulcer. Superficial ulcerations with bleeding can also be seen in patients with Crohn's disease. This finding is demonstrated in this video. Here, we see a still image showing a superficial bleeding ulcer. A stricture develops as a result of submucosal fibrosis from chronic inflammation. In this video, we see diffusely edematous villi, leading to an area of villous denudation, ulceration and stenosis, causing obliteration of the lumen. Obliteration of the lumen from a stricture is noted in this still image. This is a video clip from a patient with small bowel Crohn's disease who was noted to have localized villous edema with ulcerations and a stricture formation. The capsule was retained in the stricture. Overall, capsule retention occurs in approximately 1.4% of all capsule studies. As a general rule, a retained capsule does not cause an obstruction, but tumbles above the strictured area, where it can be retained for years, as was the case in this patient. Obliteration of the bowel lumen from a stricture is again highlighted in this histal image. NSAID entropathy is an underestimated and under-recognized entity. Common presentations include iron deficiency anemia, diarrhea, abdominal pain, and weight loss. Massive small bowel bleeding, perforation, and obstruction are rare. Capsular endoscopy findings are non-specific and include erosions, ulcers, red spots, willis denudation, and bleeding. The characteristic finding is that of diaphragm-like strictures. This is a video clip from a patient with chronic NSAID use showing a circumferential alteration leading to formation of a thin diaphragm-like membrane causing a stenosis. Pathognomonic thin membrane is noted here in this still image. Usually multiple stenotic lesions are noted in the mid-small intestine. Treatment is cessation of NSAIDs. Some patients require surgical resection of the disease segment of the small bowel. Chronic radiation arthritis can occur with clinically significant bowel injury starting at an exposure of 4,500 to 5,000 centigrade. Progressive occlusive vasculitis causes submucosal edema and inflammation, and diffuse collagen deposition causes fibrosis. These pathological changes cause abdominal pain, nausea, vomiting, diarrhea, and malabsorption. Symptoms may start as soon as six months or as long as 40 years after exposure. The diagnosis is usually established by clinical suspicion and radiological findings in patients with a prior exposure to radiation therapy. CT scan and small bowel follow-through are widely available and show findings of bowel edema and stricturing. However, these can be nonspecific and are frequently unhelpful early in the disease course. CT and MR enteroclysis are more specific, however, have limited availability only in a few specialized centers. Experience with capsule endoscopy in diagnosis of radiation arthritis is limited, but appears promising to identify mucosal changes associated with radiation arthritis, especially early in the work of these patients. Characteristic capsule findings in radiation arthritis include erythematous, edematous segments of small bowel mucosa, along with clubbed villi. Ulcers and strictures can also be seen. This video clip is taken from a patient with a history of exposure to radiation therapy several years ago for ovarian cancer who presented with abdominal pain and diarrhea. CT scan findings were nonspecific and so a video capsule endoscopy was performed. The video demonstrates diffused villus edema, clubbing of villi, and mucosal ulceration with a stricture formation. The still image from this video highlights these features of villus edema, villus denudation with ulceration, and a stricture formation. Cryptogenic multifocal ulcerative stenosing arthritis is a rare illness characterized by recurrent small bowel obstructions and or iron deficiency anemia due to multiple small intestinal fibrous strictures or multiple shallow ulcers of the small bowel. Etiology and pathogenesis of this disease process is poorly understood. Crohn's disease and non-steroidal anti-inflammatory drug use needs to be excluded. Very rarely these patients can present with diarrhea, malabsorption, or hematokesia. Absence of systemic inflammatory reaction is usually notable. The disease affects the ileum predominantly, however the terminal ileum is usually spared. The ulcers are usually multiple, more than 20. The small intestinal lesions never progress to cobblestone appearance, fissure, or fistula formation. The ulcers are restricted to the mucosa or submucosa. They never extend to the proper muscular layer. Strictures can be indistinguishable on capsule endoscopy from Crohn's disease. The disease is usually responsive to glucocorticoids. Segmental resection of affected small bowel with strictures may be required. This video is taken from a 59 year old male patient who presented with long history of iron deficiency anemia. Based on the findings of stenosis and mucosal ulcerations, as demonstrated in this video, he underwent an intraoperative endoscopy which showed 16 benign appearing intrinsic stenosis that were traversed. Segmental surgical resection showed active enteritis with mucosal ulceration and luminal stricturing. Transmural inflammation was not noted. Here we have compared the subtle differences between the small bowel ulcers in patients with Crohn's versus cryptogenic multifocal stenosing enteritis. Ulcers in Crohn's disease typically have a serpigenous outline and are often cratered. They are usually surrounded by edematous villi and are often covered with a yellow exudate. Aftoid ulcers are seen commonly. In patients with cryptogenic multifocal stenosing enteritis, ulcers typically have smooth incised margins and are surrounded by normal villi. They are covered by a white creamy exudate. Aftoid ulcers are not seen. To summarize, ulcers and strictures can be a fairly common finding on capsule endoscopy examination. Crohn's disease and NSAIDs are the most common etiology. It is often difficult to differentiate the etiology based on capsule findings alone and clinical correlation is necessary. The objectives for this section are to review the epidemiology of small intestinal tumors. We will also review the different types of tumor, both benign and malignant. We will demonstrate the appearances of a variety of different tumors by both video and still images. This will provide the opportunity to both learn how to identify tumors, identify some of the details that are important in providing details as to their nature. The incidence of small intestinal tumors is low. They comprise 1-2% of GI malignancies and up to about 6% of the tumors found are benign. Unfortunately, many of the malignant tumors found in the small intestine have already metastasized or are unresectable. However, carcinoids in the small bowel may be picked up by capsule endoscopy at a comparatively early stage and even if they have spread to local lymph nodes, complete resection appears to be curative. The demographics of small bowel tumors are well summarized in a paper by Schwartz et al. in 2007. They found that tumors were generally more common in males and the age of detection varied between 20 and 86 with a mean of 59 years. In this study, they found more malignant tumors than those that were benign. The commonest benign tumors were GIST tumors. These are also referred to as GI spindle cell tumors. They are benign when they are less than 2.5 cm in size. If they are greater than 2.5 cm with certain cellular characteristics, they tend to have malignant potential. The types of small bowel tumor and the distribution anatomically are depicted in this slide. The commonest malignant tumor of the small bowel is adenocarcinoma. The other types and the prevalence of malignant tumors in the intestine are shown in this slide. The anatomical distribution of these tumors is also summarized. The indications for capsule endoscopy in the context of tumors are predominantly those of obscure small intestinal bleeding or anemia. Abdominal pain may also draw attention to a tumor. A family history of polyposis or a personal history of a familial polyposis syndrome without any evidence of blood loss may also be an indication for capsule endoscopy. The appearances of tumor in the small intestine are variable. There is generally a mass effect and this may be associated with active bleeding, mucosal breaks, ulceration or umbilication. As is discussed elsewhere in this video, it is sometimes very difficult to visually separate an extraluminal organ protruding into the lumen from a submucosal mass. CT or MR enterography are frequently and appropriately used as complementary tests to capsule endoscopy in this context. The next part of this presentation will provide a series of images taken from capsule studies. The first part of the presentation covers some of the common benign tumors. The second part covers the malignant tumors. This slide demonstrates a large polypoid cholesterol deposit. As can be seen in the accompanying video, which has a large number of these cholesterol deposits, these lesions range in size from tiny to ten or more millimeters. They are often pleomorphic, they may be flat, slightly raised or polypoid. They are characterized by the presence of blood vessels coursing across the surface of the deposit. The color ranges from yellow to white. In the video, one of these lesions is associated with a small angioictasia, which is very unusual. These deposits are not a source of bleeding. Lymphoid hyperplasia, which is a common benign finding and is shown in the section on normal variants. Occasionally, the lymphoid tissue becomes extraordinarily prolific. In this case, it was so pronounced that it caused intussusception in the terminal ilium and presented as recurrent abdominal pain and intestinal bleeding. The lymphoid hyperplasia in this case was hemorrhagic and consisted of a multiple filiform projections into the lumen with very edematous villi that were also fragile, which bled on minimal trauma. The area of hyperplasia, which was the source of bleeding, was a few centimeters from the ileocecal valve. It proved impossible to treat this enteroscopically because of its extent, so the terminal ilium was resected and proved curative. This was thought to be a neoplastic polyp, but on close inspection, it has edematous villi at its base and is eroded at the top and capped with exudate. This is much more consistent with an inflammatory polyp. As can be seen in the next slide, careful inspection of the terminal ilium reveals multiple small ulcers and inflammation consistent with the diagnosis of small bowel Crohn's disease. Edematous villi in the center of the field and in the upper right quadrant, along with individual villus hemorrhages and small ulcers, are consistent with changes seen in Crohn's disease. ... Multiple polyps that are very pleomorphic in appearance are typical of Perts-Jäger syndrome. They may range in size from a few millimeters to several centimeters. The polyps are generally hematomas and they may be single or multiple. The presentation will now move from the benign to the malignant. ... There are at least two carcinoids in this image. As can be clearly seen, the one on the right is deeply umbilicated. ... This is a larger carcinoid tumor with umbilication. It also clearly demonstrates that there is an acute angle between the mass and the intestinal wall, implying that this is a submucosal lesion and not an external indentation. This patient, after resection of a large portion of her intestine, was found to have 57 discrete carcinoid tumors. ... The features seen in this image are thickened folds, a possible ulcer, and general disorganization of the mucosa with loss of villi. It is often possible to see active bleeding and ulceration. The passage of the capsule may cause bleeding of friable tumor tissue. In this case, the capsule passed through the tumor on the second attempt. The only abnormality on this image is of a nearly buried angioictasia seen at approximately 10 o'clock. This patient had episodes of melanoma, often months apart, and no bleeding was ever detected on repeat capsule endoscopy. Eventually, a repeat CT scan demonstrated a tumor adjacent to the proximal jejunum. As can be seen in the center of the operative field, there is a black area from a tattoo that was placed at the point of maximum insertion at deep endoscopy. No sign of the tumor was apparent. However, at surgery, it was found that the white mass was adjacent and connected to the jejunum, but not intraluminal, and this was the source of intermittent bleeding. The tumor on histology was benign and without evidence of spread. These two images of the intestine are of a metastatic melanoma. The tumor is dark, actively bleeding, and by reference to the timestamp, the capsule is retained due to stricturing caused by the tumor. Lastly, I would like to review an algorithm for the diagnosis of small intestinal tumors. So, if on capsule endoscopy you find there is something with a high or intermediate probability of it being a tumor of the small intestine, then cross-sectional imaging is the next step. If this confirms a mass, then either deep endoscopy and biopsy with a tattoo or direct progress to surgery is appropriate. If you're considering a low probability of a tumor on capsule endoscopy, then again cross-sectional imaging is appropriate. If the imaging is normal, but there is a clinical history consistent with a small bowel tumor, then deep endoscopy should be considered. If there is no convincing support for a tumor, then either observe the patient or repeat the capsule endoscopy. If the CT is abnormal, then follow the same procedure as for a high probability of a mass, namely either deep endoscopy or surgery. It is in the diagnosis and management of small bowel tumors that capsule endoscopy and cross-sectional imaging are critically important as complementary techniques. In this presentation, we will discuss the role of capsule endoscopy in evaluation of diseases of the small intestine that can cause malabsorption. With regards to findings of capsule endoscopy, malabsorptive diseases can be broadly classified as mucosal diseases, infectious diseases, diseases caused by lymphatic obstruction, and from vasculitides. Among mucosal diseases, celiac disease is the most common. Tropical sprue causes mucosal findings similar to celiac disease and is found in patients from tropical countries. Other entities such as autoimmune enteropathy, eosinophilic gastroenteritis, primary immunodeficiencies such as common variable immunodeficiency, and amyloidosis are rare. Infectious etiologies such as Vipil's disease, HIV enteropathy, and GRDSs are seldom encountered in clinical practice. Lymphatic obstruction can occur due to primary intestinal lymphangiectasia or due to secondary etiologies which can result in malabsorption. Mesenteric vasculitis from SLE or haenoxonin purpura can result in intestinal ischemia and edema, leading to a protein-losing enteropathy. Celiac disease is a gluten-sensitive enteropathy characterized by mucosal inflammation and Willis atrophy. It is estimated to occur in about 1% of the population. Endoscopic findings suggestive of celiac disease have a 50 to 94% sensitivity, however, have a high specificity at 95 to 100%. For celiac disease, common features on capsule endoscopy include scalloped mucosa, mosaic formation, and Willis atrophy. Uncommon features include ulceration, mucosal fissures, crevices or grooves, bleeding, and nodularity. Layering or stacking of folds has also been described. However, it is important to remember that all scalloping is not necessarily due to celiac disease. Scalloping of mucosa can also be seen in other diseases such as GRDS, amyloidosis, tropical sprue, eosinophilic gastroenteritis, HIV enteropathy, and Crohn's disease. This video demonstrates the characteristic signs of celiac disease including blunting of villi, scalloping of mucosa, as well as a mosaic pattern. These features are highlighted in these still images. Ulcerative jejunal ileitis is a rare but serious complication. This should be suspected in patients with celiac disease who present with weight loss, abdominal pain, and diarrhea. Capsule endoscopic findings include ulcers and strictures. Other complications include enteropathy-associated T-cell lymphoma. However, the overall risk of malignancy such as lymphoma or carcinoma is lower than previously reported. Role of capsule endoscopy for surveillance in patients with long-standing celiac disease is unclear. It is recommended that patients with alarm symptoms, despite a gluten-free diet, should have capsule endoscopy. Now we will talk about capsule findings in common variable immunodeficiency. This is the most common form of severe antibody deficiency characterized by impaired B-cell differentiation. Prevalence is reported to be about 1 in 25,000. GI manifestations occur in 10 to 20% of these patients which include inflammatory bowel disease-like illness, splew-like illness with flattening of fili, and protein-losing enteropathy. This video from a patient with common variable immunodeficiency demonstrates blunting of fili and atrophy of mucosa with prominent scalloping in the proximal small intestine. In the same patient there is evidence of prominent edematous fili along with mucosal nodularity as seen here in the terminal ileum. These still images highlight the prominent findings of the last two video clips which include scalloped mucosa, blunting of fili, as well as edematous fili. In patients with lymphangiectasia, lymphatic obstruction causes dilatation of lymphatic channels resulting in disruption of black fields which can lead to loss of proteins and chylomicrons. This can occur from primary intestinal lymphangiectasia or from secondary causes such as right-sided heart failure, constrictive pericarditis, retroperitoneal fibrosis, and radiation enteritis. In this patient with a protein-losing enteropathy, we note prominent individual villi with tiny punctates of white to yellow flecks which are present diffusely. These findings are characteristic of lymphangiectasia. This still image highlights the punctate white to yellow flecks representing the small lacteals of individual villi. Prevalence of amyloidosis of the GI tract varies with the type. It can be present in up to 60% of patients with AA amyloidosis but is present in only up to 8% of patients with AL amyloidosis. Patients can present with GI bleeding, malabsorption, protein-losing enteropathy, and chronic intestinal dysmotility. In this video clip taken from a 61-year-old male patient with primary AA type amyloidosis, we see areas of mucosal congestion as well as ulcerated mucosa. These two images show ulcers as well as mucosal congestion. To summarize, capsule endoscopy is a useful tool for evaluation of malabsorptive diseases of the small intestine. Celiac disease is the most commonly encountered diagnosis in this subset of patients. Although other diseases are uncommon, it is important to remember that many have mucosal abnormalities similar to celiac disease. In this segment, we will review some diagnostic challenges that face providers who review video capsule endoscopy. When we see an abnormality in standard endoscopy, we are able to insufflate, wash an area, poke at a lesion, or even spend additional time reviewing the lesion. The capsule unfortunately is unable to do any of these things and so we are left using a clinical scenario and video clues to help make the diagnosis. In our opinion, tumors and bulges pose the biggest challenges for readers of video capsule endoscopy. Nearly 50% of the tumors in the small bowel are submucosal and can be very difficult to differentiate from normal bulges that occur from the small bowel turning on itself or lying on top of other organs. Girelli et al. tried to develop a system to help differentiate between a tumor and a bulge. A bulge should be considered if there's no clear boundary, if the diameter is greater than its height, if the lumen is non-visible, and if its appearance in the video is for less than 10 minutes. A tumor should be considered if more than two of these criteria are not met or if there is associated mucosal abnormalities. There are other features that can be considered in the discrimination between a tumor and a bulge. These features include the presence or lack of folds overlying the lesion and whether the mucosa has the appearance of being stretched. You can also look at the angle between the lumen and the lesion. If the angle is more than 90 degrees, the overlying mucosa is not stretched and has folds, then it is likely a bulge. If these are not present, then it may be a tumor. Here is a short video illustrating these principles. You can appreciate the diameter being greater than its height, the wide angle, and the presence of folds overlying the lesion. This is a representative image of the previous video. Here you can see there is little difference between where the lesion begins and where the lesion ends. This case is close, but it does appear that the diameter is indeed wider than its height. Also note that when the lesion appears on the video, there is no visible lumen. You can also appreciate from the video that the lesion is only on the screen for a few frames, not the 10 minutes that one would expect if the lesion was pathologic. Here is another video, this one of a tumor. In this case, you will note the mucosal abnormalities overlying the lesion and the height being greater than the diameter. Here is a representative image of the tumor. As you can see, the boundary between the normal mucosa and the tumor are well-defined. The height also appears greater than the diameter. The lumen is visible when the lesion comes on screen, and there are definite changes of the overlying mucosa. You will also note that there is a sharp angle between the lesion and the mucosa of the small bowel. Next, we'll turn our attention to red spots and angiotasias. There is often debate about the importance of red spots and whether they could represent small angiotasias. The diagnosis is further made difficult, as we cannot wash the lesion or probe at the lesion to see if it will bleed. In general, red spots are less than one millimeter and often the size of a single villi. With that said, some spots may be a bit larger and may be a few millimeters across. Red spots represent a variety of pathology, including angioictasias, enteritis, NSAID injury, or even related to portal hypertensive changes. In a study we did of obscure bleeding in our institution, we found that while the incidence of angiotasias were increased close to the bleeding episode, the incidence of red spots were not, suggesting that these lesions are unrelated to the bleeding. Angiotasias, on the other hand, are always vascular. They are uniform red in color, they are flat or slightly raised, and often have distinct stellate or fern-like edges. This is a video of a red spot which comes into view in the middle of the video. This is a representative image of a red spot from this video. The lesion is tiny and does not appear to have the fern-like or stellite edges that angiotasia does. These are more images of red spots. As you can see, they are relatively small, but the border appears indistinct, and the color does not appear uniform. Contrast those images to this image. You can see that this is a flat lesion that is uniform in color. This lesion has well-circumscribed, fern-like margins. And this is a video of one of these lesions. You can appreciate the angiotasia coming into view. Sometimes, it can be difficult for an experienced endoscopist to discriminate between the two. In this case, the lesion is faint in color, but has suggestion of fern-like edges. In true indeterminate cases, the clinical scenario is very important. If the patient is getting a capsule to exclude Crohn's disease or has evidence of NSAID injury, it would be a reasonable assumption to think that these findings are related to injury or enteritis. If these lesions are the only lesions present and patients be having a video capsule endoscopy for obscure overt bleeding, one could consider that these lesions may represent small angioictasias. Bubbles also pose a problem for providers reading capsule endoscopy. They can give false impression of tumors or polyps. This has led to some centers to give some methacone to all of their patients. We usually suspect bubbles when bubbles are seen elsewhere, when the focus is altered within the same frame with an almost halo effect around the lesion, and when the lesion disappears within a few frames and the lumen is not obscured. This is a video of a bubble. You can appreciate that bubbles are seen elsewhere and that the focus is altered within this single image frame. This is a representative image from this video. Bubbles are seen elsewhere. There is a halo around the lesion, and it appears briefly, and the lumen is not obscured. To summarize, the lack of washing and insufflation poses unique challenges to the provider reading capsule endoscopy. While there are specific characteristics that can help discriminate bulges from tumors, spots from angioectasias, and tumors from bubbles, the clinical history can play a very important role.

video capsule endoscopy

procedure basics

hardware

patient preparation

indications

small bowel bleeding

Crohn's disease

tumors

malabsorptive diseases

challenges