Gastrointestinal Intervention 2014; 3(2): 89-92
Published online December 30, 2014 https://doi.org/10.1016/j.gii.2014.09.002
Copyright © International Journal of Gastrointestinal Intervention.
Meagan Gray, J. Matthew Moore, and Andrew Brock*
Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
Correspondence to:*Corresponding author. Medical University of South Carolina, 25 Courtenay Drive, ART 7100A, Charleston, SC, 29425, USA.,
Patients are commonly referred to tertiary centers for deep enteroscopy because of abnormal findings on video capsule endoscopy (VCE). The aim of this study was to determine how often clinical management changes when VCEs are reviewed by an enteroscopist prior to scheduling a procedure. A retrospective review was performed of patients referred for deep enteroscopy because of abnormal capsule endoscopy. All VCE images were reviewed prospectively by the tertiary center’s enteroscopist. Patients were then scheduled for deep enteroscopy or other management based on the capsule review. The rate of disagreement in the capsule findings, changes in management, and the diagnostic and therapeutic yield of enteroscopy were calculated. Video capsule endoscopy was available in 45 patients who were referred for deep enteroscopy. The mean age was 61 years (51% were females). Indications included obscure GI bleeding (37 patients), abnormal imaging (3 patients), abdominal pain (2 patients), Peutz-Jegher syndrome (2 patients), and weight loss (1 patient). Referring physician findings included polyps or masses (13 patients), angioectasia (13 patients), ulcers (9 patients), active bleeding (9 patients), nonspecific findings (8 patients), and normal (2 patients). A capsule review led to disagreement of the findings of 13 (29%) patients and led to a change in the management of 9 (20%) patients. The most common reason for a change in management was overcalled lesions. Thirty-seven patients underwent enteroscopy with a diagnostic yield of 48.8% and therapeutic intervention in 24.4%. A review of referral VCE studies led to a change in management in a large percentage of patients, particularly when the indication was polyp, mass, or ulcer. Patients referred for deep enteroscopy should have their capsule re-read by an enteroscopist prior to scheduling the procedure.Background
Methods
Results
Conclusion
Keywords: deep enteroscopy, review, video capsule endoscopy
Video capsule endoscopy (VCE) is widely used in the community for the diagnosis of small bowel disorders. However, deep enteroscopy is generally only performed at tertiary care centers. Thus, when lesions are found that require deep enteroscopy, patients are referred to a tertiary center, often in an open-access manner. Procedures are commonly scheduled, based on the referring physician’s interpretation of the capsule findings, but precise anatomic locations of lesions, route of insertion (i.e., antegrade vs. retrograde), and interpretation of capsule findings may be unspecified or incorrect.
At our institution, we reviewed capsule endoscopies prior to scheduling procedures to determine whether deep enteroscopy versus another endoscopic or nonendoscopic test is required, and determine the best route of insertion. Patients are referred in an open-access manner, although only those who will likely benefit from deep enteroscopy (as determined by the enteroscopist) are scheduled for the procedure. Our primary aim was to determine how often changes in clinical management are made for patients who are referred for deep enteroscopy when capsules are reviewed by the enteroscopist prior to scheduling the procedure.
We conducted a retrospective analysis of all patients referred to the Medical University of South Carolina (Charleston, SC, USA) between July 2011 and February 2013 for deep enteroscopy inwhom the video capsule disc was available for review. Patients were excluded if the VCE had not been reviewed by the enteroscopist before scheduling the procedure. This study was approved by the Institutional Review Board of the Medical University of South Carolina.
All capsule endoscopies included in this study used the PillCam SB2 capsule system (Given Imaging, Yoqneam, Israel). No other capsule brands are used by our referral base; therefore, no patients were excluded based on the capsule manufacturer. Capsules were not always made available by the referring physician or, for some patients, were sent on an unreadable disc. In this eventuality, patients were excluded from analysis for this study.
All capsules were first reviewed by the referring physician, and then reviewed prospectively by a single tertiary care physician (A.S.B.), who reads approximately 100 VCEs per year. The capsules were reviewed in their entirety, with a particular focus on abnormal areas thumb-nailed by the referring physician. Interpretation of the capsule findings was prospectively recorded on RAPID for PillCam software (Given Imaging, Yoqneam, Israel).
Enteroscopy was performed by a single endoscopist (ASB, who performs over 100 deep enteroscopies annually), by using a single balloon system (SIF-180; Olympus Medical, Center Valley, PA, USA). Antegrade and retrograde approaches were determined at the discretion of the endoscopist. The standard technique was used.1
Data were obtained from the RAPID for PillCam database (Given Imaging), endoscopy database, and institutional electronic medical records. The data collected included the indications for capsule endoscopy, VCE interpretation by the referring physician, VCE interpretation by the tertiary care physician, the results of enteroscopy and/or other subsequent tests, and the demographic data. The rate of disagreement in the capsule findings and rate of changes in management, and the diagnostic yield of therapeutic interventions in patients undergoing deep enteroscopy were calculated.
Outside VCE discs were available for 45 patients who were referred for deep enteroscopy. All patients were included in this analysis. The mean age of the patients was 61 years (18–79 years) and 23 (51%) patients were female (Table 1). Indications for VCE included obscure GI bleeding (37 patients), abnormal imaging (3 patients), abdominal pain (2 patients), Peutz-Jegher syndrome (2 patients), and weight loss (1 patient). The referring physician findings included polyps or masses (13 patients), angioectasia (13 patients), ulcers (9 patients), active bleeding (9 patients), nonspecific findings (8 patients), and normal (2 patients). Many patients had more than one finding. Thirty-eight (84.4%) patients were referred for antegrade single balloon enteroscopy (ASBE); 3 (6.7%) patients, for retrograde single balloon enteroscopy (RSBE); 2 (4.4%) patients, for push enteroscopy; and 2 (4.4%) patients, for a second opinion.
Capsule review led to disagreement in the findings of 13 (28.8%) patients (Table 2). Of these 13 patients with discordant findings, there were 11 overcalled lesions, five missed lesions, and three lesions with misidentified locations. Most patients had multiple discordant findings. Overcalled lesions included masses or polyps (5 patients; Figs. 1 and 2); ulcers (4 patients); and angioectasias (2 patients). Missed lesions included angioectasias (2 patients; Fig. 3); gastric antral vascular ectasia (GAVE)/portal hypertensive gastropathy and enteropathy (1 patient); and nonspecific enteropathy (1 patient).
Nine (20%) patients required a change in management (Table 3). Conservative management was recommended for two patients secondary to overcalled lesions. There were two additional patients who were also treated with conservative management because of overcalled lesions; however, these patients were referred for a second opinion and could not be counted as a change in management. Overcalled lesions included polyps, masses, or angioectasias that were actually folds, insignificant erythema, light reflex, or food debris. Two patients with multiple small bowel angioectasias were recommended to have conservative management because of multiple comorbidities and/or lack of the need for blood transfusion. One patient was deferred for enteroscopy in favor of cross-sectional imaging; magnetic resonance enterography revealed a carcinoid tumor and the patient subsequently underwent its surgical resection. Two patients underwent ASBE instead of push enteroscopy and one patient underwent RSBE instead of ASBE because of a misidentified lesion location. One patient underwent repeat colonoscopy instead of ASBE because of a lesion that was read as a small bowel polyp but was actually a colonic fold. In total, 37 patients underwent enteroscopy with a diagnostic yield of 48.8% and therapeutic intervention of 24.4%. There were no immediate or delayed adverse events.
Capsule endoscopy is becoming increasingly common for the initial investigation of suspected small bowel pathology.2 The relative ease, low risk, and minimal training requirements have made it widely available in academic settings and in private practice settings. Abnormal findings often require deep enteroscopy, which is typically only available at tertiary care centers. Patients are often referred in an open-access manner, which is acceptable as long as there is a good indication. At our institution, we re-read capsules whenever possible, particularly if there is doubt about the indication.
In this study, we found that changes in management after rereading capsule endoscopies were because of lesion misdiagnosis, incorrect lesion location, or inappropriate route of insertion requested. Diagnostic errors may result from a lack of experience and training in capsule endoscopy, but even among experts there is interobserver variability in capsule interpretation.3–5 It has been previously suggested that a second reading by an experienced viewer may improve the diagnostic accuracy of VCE.6 An inaccurate lesion location may result from a lack of familiarity with the length of each small bowel segment or result from the use of gross time estimates rather than small bowel transit time, as discussed below. Improper recommended route of insertion is likely to be secondary to a lack of understanding of the depth limitations of antegrade and/or retrograde enteroscopy. Enteroscopists may have an advantage in determining lesion location/route of insertion and in recognizing small bowel pathology on VCE because they regularly visualize the correlating lesions during enteroscopy. Previous studies have not compared VCE interpretation between endoscopists who perform enteroscopy and those who do not.
Capsule endoscopy differs from other imaging modalities in that it can only give an estimate of where a lesion may be in the small bowel. To overcome this difficulty, the small bowel transit time was developed. By using the first duodenal image and first cecal image, each small bowel image is given an estimated percentage of small bowel covered out of the total small bowel transit. This technique has been validated for determining the route of insertion for enteroscopy. For example, lesions up to 36% through the small bowel can be reliably reached by ASBE.7 Most readers, however, still use gross time through the bowel, rather than the percent progress, to estimate a lesion’s anatomic location. This technique does not take into account gastric transit time or pauses in capsule movement because of stricture or lack of peristalsis. These errors may lead to an inaccurate estimation of lesion location and subsequent incorrect mode of enteroscopy. Disagreement in lesion location led to a change in management in two (4.4%) patients in this study.
There is a significant false positive rate with capsule endoscopy.3,8,9 This is particularly true with polyps and ulcers, although angioectasias and masses are also frequently overcalled.3,10–12 Criteria have been developed to help differentiate submucosal tumors from folds; however, the criteria remain a very challenging aspect of VCE.13,14 Our study was consistent with these observations in that the most common overcalled lesions were masses/polyps5 and ulcers.4 There were also three instances in which angioectasias were present that were missed or mistaken for erosions or ulcers. These patients underwent ASBE for a different indication than originally intended, but the overall management was not changed.
The limitations of this study include the small number of patients and readings were performed by a single enteroscopist at a single center. Our results nonetheless demonstrate that reviewing capsule endoscopies prior to enteroscopy results in a substantial number of changes in management. These changes are not insignificant in that they may lead to a different route of insertion, a different modality (e.g., cross-sectional imaging), or obviate the need for further work-up. If abstracted to a larger scale, re-reading could substantially decrease cost, resource utilization, and the performance of potentially unnecessary procedures. In conclusion, reviewing capsule endoscopies in patients referred for open-access enteroscopy changes management in a large proportion of patients. If not employed for all patients, this process should at least be performed when there is any doubt as to the indication for enteroscopy or route of insertion.
Patient Characteristics and Vce Indications and Findings
Demographics | |
---|---|
Mean age, y (range) | 61 (18–79) |
Female | 23 |
Male | 22 |
Indications for VCE | |
Obscure GI bleeding | 37 |
Abnormal imaging | 3 |
Peutz-Jegher syndrome | 2 |
Abdominal pain | 2 |
Weight loss | 1 |
VCE findings, | |
Polyps/masses | 13 |
Angioectasia | 13 |
Active bleeding | 9 |
Ulcers | 9 |
Nonspecific mucosal abnormality | 8 |
Normal | 2 |
VCE, video capsule endoscopy.
Discordant Findings
Referring physician interpretation | Requested procedure | Capsule review | Procedure | Findings | |
---|---|---|---|---|---|
1 | No source of bleeding encountered | ASBE | Angioectasia at 9%, 20%, and 72% | ASBE | Normal |
2 | Proximal small bowel ulcer | ASBE | Angioectasias in the duodenum, proximal jejunum, proximal ileum and mid-ileum. Bubble artifact rather than ulcer | ASBE | Angioectasias in the duodenum and jejunum treated with APC |
3 | Multiple submucosal nodules and polyps throughout the small bowel | ASBE | All folds | Observation | N/a |
4 | Angioectasias and ulcerated lesions in the duodenum | PE | Erythema and focal swelling/mass 8% into the small bowel | ASBE | Normal |
5 | Submucosalmass in the mid-small bowel | ASBE | Reversed view of the pylorus rather than submucosal lesion. Enteropathy | ASBE | Normal |
6 | Small bowel polyp | ASBE | Colonic fold | Colonoscopy to exclude polyp | Normal colonoscopy |
7 | Distal duodenal angioectasias and gastritis | PE | Angioectasias in the mid-jejunum | ASBE | Normal small bowel |
8 | Multiple small bowel angioectasias; ulcer | ASBE | Multiple small bowel angioectasias; no ulcer | Enteroscopy deferred because of multiple comorbidities and no ulcer present | N/a |
9 | Mass/lipoma in the mid-small bowel | ASBE | Duodenal angioectasias. The “mass” was light reflex artifact | ASBE | Duodenal and jejunal angioectasias treated with APC |
10 | Ileal ulcer | ASBE | Food debris; no ulcer present | Enteroscopy deferred | N/a |
11 | Possible jejunal angioectasia | 2nd opinion | Normal | Enteroscopy deferred | N/a |
12 | Submucosal lesion in the distal ileum | 2nd opinion | Fold rather than submucosal lesion | Enteroscopy deferred. | N/a |
13 | Jejunal ulcer | ASBE | Ulcer in mid-ileum | RSBE | Benign ulcer in the mid-ileum |
Changes in Management
Referring physician interpretation | Requested procedure | Capsule review | Management change | Outcome | |
---|---|---|---|---|---|
1 | Multiple submucosal nodules and polyps | ASBE | All folds | Enteroscopy deferred | N/a |
2 | Angioectasias and ulcerated lesion in the duodenum | PE | Erythema and focal swelling/mass 8% into the small bowel | ASBE | Normal |
3 | Small bowel polyp | ASBE | Colonic fold | Colonoscopy to exclude polyp | Normal |
4 | Distal duodenal angioectasias and gastritis | PE | Angioectasias in the mid-jejunum | ASBE | Normal small bowel |
5 | Multiple small bowel angioectasias; ulcer | ASBE | Multiple small bowel angioectasias; no ulcer | Enteroscopy deferred because of multiple comorbidities and lack of ulcer | Iron therapy |
6 | Ileal ulcer | ASBE | Food debris; no ulcer | Enteroscopy deferred | N/a |
7 | Ulcerated mass versus ulcer with edema in proximal to the mid-ileum | ASBE | Ulcerated mucosal mass in proximal to the mid-ileum | Enteroscopy deferred. MRE performed | Ileal carcinoid tumor; surgery |
8 | Multiple proximal small bowel angioectasias | ASBE | Multiple proximal small bowel AVMs | Enteroscopy deferred because no blood transfusions were required | N/a |
9 | Jejunal ulcer | ASBE | Ulcer in mid-ileum | RSBE | Benign ulcer in the mid-ileum |
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