1. Small Bowel Bleeding and Capsule Endoscopy
Department of Gastroenterology

2. Obscure Gastrointestinal Bleeding(OGIB)
Definition
Bleeding of unknown origin that persists or recurrs after a negative initial or primary endoscopy (colonoscopy and/or upper endoscopy)
Incidence
5% of all GI bleeding problems
These patients often have lesions in the small bowel, out of reach from the usual endoscopic techniques

3. Cause of small bowel bleeding
Vascular abnormality: most common (70~80%)
Angioectasis, Dieulafoy lesion, vascular enteric fistula, small bowel varices
Ulcers and other inflammatory lesion (10~12%)
Crohn disease is most common
NSAIDs induced, vasculitis, ischemia, infections
Small bowel neoplasm (5~10%)
5% of all tumors in the GI tract
Benign lesion is more common  vigorous bleeding
Polyp, lymphoma, stromal tumor, metastatic lesions
Diverticular disease

4. Diagnostic studies Small bowell series and enteroclysis
Diagnostic rate : 5~10 %

5. Diagnostic studies Tagged red blood cell scans Angiography
Useful in the evaluation of active GI bleeding
More likely to localize when the rate of blood loss exceeds 0.1~0.4 mL/min
Angiography
Diagnostic rate is 25%, non-active bleeding
40~50%, bleeding at a rate of 0.5mL/min
Figure: technetium labelled RBC scan showing extravasation of radiolabelled blood in a loop of ileum(arrow)

6. Diagnostic studies Push enteroscopy Intraoperative enteroscopy
Diagnostic rate 40~50%
The entire small bowel cannot be visualized
Time-consuming
Not well tolerated by patients
Intraoperative enteroscopy
Diagnostic rate 70~80%
But most invasive

8. Video Capsule Endoscopy (VCE)

9. Features of VCE Capsule takes two images per second Battery: 8hrs
On average, 50,000~60,000 images are obtained during an 8 hour exam
Lens: 140°, 8x
Capsule coating: non-adherant
Disposable
Interpretation: about 1hr

10. Performance Overnight 12 hour fast Sensors placed on patient
Patient wears a belt that contains a battery pack and data recorder.
Patient ingests capsule
Patient may have clears fluids two hours after ingestion
Patient may have a light lunch 4 hours after ingestion
Avoid other patients who ingested a capsule.
Patient returns 7-8 hours later

11. Indications Occult gastrointestinal bleeding.
Suspected Crohn’s disease.
Suspected small bowel tumor.
Surveillance of inherited polyposis syndromes.
Evaluation of abnormal small bowel imaging.
Evaluation of drug-induced small bowel injury.
Partially responsive celiac disease.

12. Contraindications Absolute:
Known or suspected obstruction/stricture/fistula/extensive
Crohn's disease
Swallowing disorders
Pseudo-obstruction
Motility disorders
Cardiac pacemakers/Implanted defibrillators
Relative:
Pregnancy
Longstanding nonsteroidal anti-inflammatory drug use
Large and numerous diverticuli
Gastroparesis
Previous pelvic or abdominal surgery

13. Complication
Capsule retention is the major and for practical purposes the only complication of capsule endoscopy
Patency capsule
(Curr Opin Gastroenterol : )

14. GE Junction
Duodenum
Jejunum
Ileocecal Valve

15. Phlebectasia
AVM
Lymphangectasia
Bleeding Lesion

16. Lymphoma
GIST
Polypoid Mass
Polyp

17. NSAID stricture
Radiation Enteritis
Sprue
Villous Drop Out

18. Comparison with other modalities in OGIB
Significant increased diagnostic yield of capsule endoscopy over push enteroscopy and other modalities in OGIB
Diagnostic rate : 55~70%
At the time of overt bleeding: success rate 92%
Pennazio M, et al. Outcome of patients with obscure gastrointestinal bleeding after endoscopy: report of 100 consecutive cases. (Gastroenterology 2004; 126:643–653)

19. ICCE 2005 Consensus for OGIB (Endoscopy 2005;37:1046-1050)

20. ICCE 2005 Consensus for OGIB (Endoscopy 2005;37:1046-1050)
the number of hospitalizations, tests,
procedures, and units of blood transfused
ICCE 2005 Consensus for OGIB (Endoscopy 2005;37: )

21. Limitation 진단 이외에 조직생검이나 치료가 불가능
검사에 8시간, 판독에 1시간 이상이 걸리므로 급성 장출혈 환자의 경우 사용이 어렵다.
시야 확보가 어려운 경우가 있다.
밧데리 수명 때문에 전체 장을 관찰하지 못하는 경우가 있다.
검사비가 고가이다.(우리나라의 경우)
높은 진단율이 실제 환자의 임상 경과에 미치는 영향에 대해서는 아직 밝혀진 바 없다.
Retention된 경우 수술이 필요할 수 있다.

22. Double Balloon Endoscopy (DBE)

23. Double Balloon Endoscopy (DBE)
2001년 Yamamoto등에 의해 처음 소개
실시간으로 소장의 관찰, 조직 생검 및 치료가 가능해짐
Diagnostic rate: 70 ~ 80%
단점: 검사 시간이 오래 걸리고, 넓은 범위의 관찰을 위해서는 경구 및 경항문 검사가 모두 필요하며, 이 경우에도 80%의 환자에서만 전체 소장의 관찰이 가능

24. and Obscure Gastrointestinal Bleeding
American Gastroenterological Association Medical Position Statement: Evaluation and Management of Occult
and Obscure Gastrointestinal Bleeding
(GASTROENTEROLOGY 2000;118:197–200)
Capsule Endoscopy

25. ICCE 2005 Consensus for OGIB (Endoscopy 2005;37:1046-1050)