1. Is the capsule a guiding star ? Dr. Niv Eva Department of Gastroenterology Tel-Aviv Sourasky Medical Center

4. First Case

5. 44 y.o. woman 13 years ago Abdominal pain, diarrhea Normal colonoscopy+ileoscopy (including biopsies) Small bowel passage– thickening of middle part of small bowel Diagnosis: Crohn’s disease of mid- small intestine Treatment: Azathioprine ( 3-4 y)– good response, but leukopenia  stopped 5ASA, prednisone– good response Recently asymptomatic  all medications stopped

6. 10 months ago Abdominal pain, diarrhea, weight loss Hypokalemia, hypomagnesemia, anemia, hypoalbuminemia (3.0 g/dL) Two weeks later– hospitalization small intestinal intussusception CT: Thickening of all small intestine (especially – mid), mesenteric lymphadenopathy

7. Conservative treatment Resolution of intussusception  discharge Follow up visit in the Dept of Gastroenterology Looks ill, still abdominal pain severe diarrhea (~2000 cc of stool/day), weight loss (6-7 kg), BMI 19, hypoalbuminemia (2.7 g/dL)

8. Ileo-colonoscopy– normal Normal biopsies from colon and terminal ileum Video capsule endoscopy (another medical center) Normal Small Intestinal Mucosa. Revision of the film…

9. Normal small intestinal mucosa

11. What is the diagnosis of the patient ?

12. Scalloped folds, lack of villi, mosaic pattern Diagnosis— Celiac disease DD:Lymphoma, Mastocytosis, Eosinophilic gastroenteritis, Hypogammaglobulinemia, Giardiasis, Tropical sprue

13. Enteroscopy

15. The mystery was resolved: No evidence of Crohn’s disease The recent deterioration was explained by wheat- based diet Celiac disease is a known cause of intussusception Gluten-free diet was started with quick improvement Anti TTG positive (high titer) The diagnosis of celiac disease was established The possibility of T cell lymphoma was excluded

16. Folow up in 10 months The patient adheres to gluten-free diet The patient is asymptomatic Normal nutritional state, normal blood tests

17. Summary of First Case In this case capsule endoscopy was a blessing by finding the right diagnosis when other imaging tests were misleading.

18. Endoscopy 2005 ICCE Consensus for Celiac Disease,,All video capsule endoscopists need to be familiar with the changes characteristic of celiac disease.’’ Indications for capsule endoscopy in celiac disease: 1.Persistent or alarm symptoms in patients with established celiac disease 2.Initial diagnosis in patient with positive celiac serology who is unwilling or unable to undergo EGD

19. Second Case

20. 74 y.o. male IHD, s/p CABG X2, recently asymptomatic PAF Medications: amiodarone, clopidogrel 2 y.a.– Laparoscopic inguinal hernia repair 1 y.a.—Small bowel obstruction Laporoscopic adhesiolysis (a few adhesions in unrelated area)

21. During the following 6 months– Recurrent episodes of small intestinal obstruction Conservative treatment CT abdomen– Thickening and mild dilation of mid-small intestinal loop

22. On the basis of clinical picture surgery was planned But the surgeon asked to perform capsule endoscopy first

23. Small submucosal lesion Discrete areas of inflammation and erosions

24. Stricturing ulcers

25. What is the differential diagnosis of the patient ? What should be the strategy ?

26. DD Crohn’s disease NSAIDs or other medications Lymphoma TB Ischemia due to atherosclerosis or intermittent intussusception (submucosal tumors, adhesions) Ulcerative jejunoileitis

27. Work-up No medications except for amiodarone and clopidogrel Lab tests– CBC, SMA, CRP normal Colonoscopy (including biopsies)– normal Gastroscopy– normal Enteroscopy (including biopsies)– normal ASCA, ANCA negative

28. The dilemma: To operate or to give empirical treatment Decision– prednisone trial prednisone 40 mgx1 for 2 weeks—failure Tapering down

29. Operation No evidence of Crohn’s disease (no transmural inflammation, no fat wrapping) No evidence of lymphoma (no lymphadenopathy) Normal small bowel (outside view) Multiple adhesions with segmental pressure on small bowel Biopsy from adhesions: Fibrotic tissue. No granulomas Suggestion: adhesions and recurrent episodes of small bowel obstruction caused secondary ischemic changes in the bowel

30. Am J Surg 2005; 190: 886-90 The utility of capsule endoscopy and its role for diagnosing pathology in the GI tract Carlo JT et al

31. Follow up in 6 months The patient is asymptomatic No additional events of small bowel obstruction

32. Summary of Second Case In this case capsule endoscopy delayed the definitive treatment (operation) by several months

34. Thank you for your attention