This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. Hi, my name is Gerard Eisenberg, and I'll be talking about differentiating between folds or bulges and submucosal lesions on small bowel capsule endoscopy. It's sometimes challenging for capsule endoscopists to differentiate between a prominent fold or bulge versus a submucosal lesion. Because of health care costs associated with additional endoscopic procedures, including deep small bowel enteroscopy, it is important that only findings consistent with the submucosal lesion are potentially referred for additional evaluation and management. This video tip series will provide you with guidance differentiating between these findings. I'm going to show you a series of videos and ask if you can identify whether or not this is a prominent fold versus a submucosal lesion. Here's our first example. So I think many of you appreciated that the capsule was in the stomach before entering the duodenum and then flipped around to show a retrograde view of the pylorus. It is important when determining the possibility of a submucosal lesion, the exact location of the capsule device, particularly within the duodenum, as often retrograde views of the pylorus can be mistaken for submucosal lesions. Here's another example. This is an area that appears suspicious for either a bulge or prominent fold, and some of the things to look for are whether or not this area seems to change in shape over time. You notice that it did. In addition, the villi overlying this area appear normal. This is most consistent with the prominent fold or bulge. Here's another example. Again, this area seems to change in shape over time, and in addition, the villi overlying this area are normal. Here's an area with a red spot overlying a prominent fold or bulge. Again, the villi here look typically normal with a uniform pattern, and it does change shape over time. Some of you noticed this particular lesion on the video. This particular lesion is a submucosal lesion. It has an altered appearance of the villi, almost absent on the surface, and there is a yellowish-whitish color to the lesion. This is a lipoma. I'm sure that many of you saw this particular lesion. In fact, on one of the views, there was an ulceration on the surface. This is consistent with the submucosal lesion. Many times, gastrointestinal stromal cell tumors outgrow their blood supply, and surface ulcerations form, causing occult or overt bleeding to occur. Again, some of you picked up on the few images within this video that there was this particular lesion. This lesion also has an ulceration on the surface. In addition, there is altered villus pattern. The shape remains the same throughout the video. Some of you have noticed those yellowish submucosal nodules or plaque-like lesions. Those are lymphangiectasias. But in addition, in this video, which is of a note, there is a polyploid-type area or submucosal lesion that's seen. And again, the surface of the lesion is altered. There's variability with the villus pattern, and there's some erythema within the central portion of it. So take home points. Prominent folds typically have changes with each successive image. The villus pattern is often normal on the surface, and the mucosal color is uniform. Whereas submucosal lesions tend to maintain their shape on successive images, the villus pattern is often altered. There's often prominent villi or villi that appear abnormally large or spaced out or irregular. And sometimes you see mucosal disruption. The mucosal color is often variable, and it can be associated with surface ulcerations. When you have a suspected submucosal lesion, one of the first things that you might want to consider is performing a CTE or MRE. This allows an endoscopist or the physician managing the patient to determine whether or not this particular lesion is in reach of either a retrograde or an anti-grade balloon-assisted enteroscopy or device-assisted enteroscopy. In addition, the CTE or MRE may provide useful information as to whether or not there's any other involvement of a tumor, including lymph nodes, that might be useful in determining subsequent treatment for this patient. So many times after this is done, patients undergo a device-assisted enteroscopy to either biopsy or tattoo the lesion, or they go straight to surgery depending on the location and clinical suspicion of the lesion. Many times people who undergo device-assisted enteroscopy also subsequently undergo surgery with the help or assistance of having a tattoo placed. For further information, here are some references, and I encourage you to subscribe to GI Now. Thank you.

differentiate

folds

bulges

submucosal lesions

small bowel capsule endoscopy