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Aim: To compare clinical success and complications of uncovered self-expanding metal stents (SEMS) vs covered SEMS (cSEMS) in obstruction of the small bowel.
Methods: Technical success, complications and outcome of endoscopic SEMS or cSEMS placement in tumor related obstruction of the duodenum or jejunum were retrospectively assessed. The primary end points were rates of stent migration and overgrowth. Secondary end points were the effect of concomitant biliary drainage on migration rate and overall survival. The data was analyzed according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.
Results: Thirty-two SEMS were implanted in 20 patients. In all patients, endoscopic stent implantation was successful. Stent migration was observed in 9 of 16 cSEMS (56%) in comparison to 0/16 SEMS (0%) implantations (P = 0.002). Stent overgrowth did not significantly differ between the two stent types (SEMS: 3/16, 19%; cSEMS: 2/16, 13%). One cSEMS dislodged and had to be recovered from the jejunum by way of laparotomy. Time until migration between SEMS and cSEMS in patients with and without concomitant biliary stents did not significantly differ (HR = 1.530, 95%CI 0.731-6.306; P = 0.556). The mean follow-up was 57 ± 71 d (range: 1-275 d).
Conclusion: SEMS and cSEMS placement is safe in small bowel tumor obstruction. However, cSEMS is accompanied with a high rate of migration in comparison to uncovered SEMS.
Dieulafoy's lesion (DL) is a rare source of gastrointestinal tract bleeding that may occur at any site in the gastrointestinal tract and may be difficult to detect by endoscopy. DL is characterized by a large, tortuous arteriole in the submucosa. This is a case of duodenal DL that is detected and treated by endoscopy. This article is part of an expert video encyclopedia.
Small bowel endoscopy is crucial for diagnosing small bowel Crohn’s disease, and capsule endoscopy is complemented by balloon-assisted enteroscopy to take biopsies and by magnetic resonance imaging to visualize enteral and extra-intestinal involvement. Recently, imaging has also become a key instrument to manage Crohn’s disease patients. Treatment control is advised for patients who have undergone bowel resections and is increasingly used to testify treatment success in non-operated patients, too. In this review we present the modern imaging methods to diagnose and to manage Crohn’s disease with a special focus on the small bowel. Moreover, current knowledge on the impact of diagnostic methods on the patients’ outcome is reported.
Background/Aims: Reliable and especially widely accepted preventive measures are crucial to further reduce the incidence of colorectal cancer (CRC). Colon capsule endoscopy (CCE) might increase the screening numbers among patients unable or unwilling to undergo conventional colonoscopy. This registry trial aimed to document and determine the CCE indications, findings, complications, and adverse events in outpatient practices and clinics throughout Germany.
Methods: Patients undergoing CCE between 2010 and 2015 were enrolled in this prospective multicenter registry trial at six German centers. Patient demographics, outcomes, and complications were evaluated.
Results: A total of 161 patients were included. Of the CCE evaluations, 111 (68.9%) were considered successful. Pathological findings in the colon (n=92, 60.1%) and in the remaining gastrointestinal tract (n=38, 24.8%) were recorded. The main finding was the presence of polyps (n=52, 32.3%). Furthermore, five carcinomas (3.1%) were detected and histologically confirmed later. Adequate bowel cleanliness was more likely to be achieved in the outpatient setting (p<0.0001). Interestingly, 85 patients (55.6%) chose to undergo CCE based on personal motivation.
Conclusions: CCE seems to be a reliable and safe endoscopic tool for screening for CRC and detecting other diseases. Its patient acceptance and feasibility seems to be high, especially in the outpatient setting.
Small bowel tumors are detected in approximately 10% of patients with small bowel endoscopies for obscure or overt mid-intestinal bleeding. Small bowel tumors may be of malignant or benign etiology. Malignant etiologies include adenocarcinoma, neuroendocrine tumors, or lymphoma, whereas benign lesions are typically lipomas, inflammatory polyps, or adenomas. Within the group of nonneoplastic lesions inflammatory polyps are most frequent. Significant bleeding and bowel obstruction due to intussusception might occur, and surgical or endoscopic treatment has been reported for symptomatic patients. A case is demonstrated with an inflammatory fibroid polyp detected by capsule endoscopy and confirmed by balloon enteroscopy. This article is part of an expert video encyclopedia.
The small bowel is essential to sustain alimentation and small bowel Crohn's disease (CD) may severely limit its function. Small bowel imaging is a crucial element in diagnosing small
bowel CD, and treatment control with imaging is increasingly used to optimize the patients outcome. Thereby, capsule endoscopy, Balloon-assisted enteroscopy, and Magnetic resonance imaging have become key players to manage CD patients. In this review, role of small bowel imaging is detailed discussed for use in diagnosing and managing Crohn's disease patients.
Endoscopic retrograde cholangiopancreatography (ERCP) offers an effective interventional option for treating symptomatic chronic pancreatitis. Endoscopic pancreatic sphincterotomy is performed to facilitated endoscopic treatment. Pancreatic duct strictures can be treated by inserting plastic stents, and a 10 Fr endoprosthesis is adequate in many cases. Before stent insertion, hydrostatic balloon dilation is needed in some cases. Pancreatic stones can be removed with a dormia basket, but combining ERCP and extracorporeal shockwave lithotripsy (ESWL) is often most effective.
Standard and advanced endoscopic treatment approaches are delineated in this article and include stricture dilation with a Soehendra retriever, cSEMS placement and multi-stenting.
Celiac disease (CD) is an immune-mediated enteropathy that is characterized by intraepithelial lymphocytosis, crypt hyperplasia, and villous atrophy. Prevalence is high and has been estimated to range between 0.5% and 1.5%. Capsule endoscopy (CE) has a sensitivity and specificity of approximately 90%. CD is an important differential diagnosis for diagnostic workup for anemia, malabsorption, or diarrhea, and must be recognized reliably by the investigator. Moreover, CE is the preferred method to screen for complications in CD, such as enteropathy-associated T-cell lymphoma, ulcerative jejunitis, and small bowel adenocarcinoma. This article is part of an expert video encyclopedia.
Background: Intestinal perforation or leakage increases morbidity and mortality of surgical and endoscopic interventions. We identified criteria for use of full-covered, extractable self-expanding metal stents (cSEMS) vs. "Over the scope"-clips (OTSC) for leak closure.
Methods: Patients who underwent endoscopic treatment for postoperative leakage, endoscopic perforation, or spontaneous rupture of the upper gastrointestinal tract between 2006 and 2013 were identified at four tertiary endoscopic centers. Technical success, outcome (e.g. duration of hospitalization, in-hospital mortality), and complications were assessed and analyzed with respect to etiology, size and location of leakage.
Results: Of 106 patients (male: 75 (71%), female: 31 (29%); age (mean ± SD): 62.5 ± 1.3 years, 72 (69%) were treated by cSEMS and 34 (31%) by OTSC. For cSEMS vs. OTSC, mean treatment duration was 41.1 vs. 25 days, p<0.001, leakage size 10 (1-50) vs. 5 (1-30) mm (median (range)), and complications were observed in 68% vs. 8.8%, p<0.001, respectively. Clinical success for primary interventional treatment was observed in 29/72 (40%) vs. 24/34 (70%, p = 0.006), and clinical success at the end of follow-up was 46/72 (64%) vs. 29/34 (85%) for patients treated by cSEMS vs. OTSC; p = 0.04.
Conclusion: OTSC is preferred in small-sized lesions and in perforation caused by endoscopic interventions, cSEMS in patients with concomitant local infection or abscess. cSEMS is associated with a higher frequency of complications. Therefore, OTSC might be preferred if technically feasible. Indication criteria for cSEMS vs. OTSC vary and might impede design of randomized studies.
Peutz–Jeghers syndrome (PJS) is a rare autosomal-dominant inherited disorder characterized by gastrointestinal hamartomas, mucocutaneous pigmentation, and an elevated cancer risk. Moreover, intussusception risk may be as high as 50% at the age of 20 years and is caused by large polyps. There is some evidence that endoscopic surveillance of PJS patients with removal of small intestinal polyps with a diameter of more than 15 mm efficiently prevents intussusceptions. In recent years, capsule endoscopy (CE) has largely replaced small-bowel radiography techniques to screen for small-bowel polyps. Magnetic resonance imaging may be equally efficient as CE for screening of large polyps. Balloon enteroscopy may be used for endoscopic snare resection of polyps. This article is part of an expert video encyclopedia.
The author presents the case of a patient with severe bleeding from a duodenal ulcer that could not be controlled by endoscopic application of metal clips and injection of fibrin glue. Angiographic embolization with placement of coils into the feeding vessel stopped the bleeding. However, 3 days later, a fistula emerged from coil material penetrating into the dorsal duodenum and a peritoneal leakage developed. The fistula was completely closed by placing an over-the-scope clip on the enteral opening of the fistula. This article is part of an expert video encyclopedia.
Small-bowel tumors are rare and account for approximately 5% of all gastrointestinal tumors. Approximately 65% of small-bowel tumors are malignant, and approximately 40% of these tumors are adenocarcinomas. Similar to colorectal adenocarcinoma, premalignant adenomas of the small bowel may progress to carcinoma. This occurs both sporadically and in the context of hereditary tumor syndromes such as familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer (Lynch syndrome). Herein cases with small-bowel adenocarcinomas visualized with both capsule endoscopy and double-balloon enteroscopy are presented. This article is part of an expert video encyclopedia.
A rare cause of recurrent melena was identified by capsule endoscopy: arteriovenous malformation
(2013)
Small bowel endoscopy is indicated for patients with an unidentified bleeding site in esophagogastroduodenoscopy and ileocolonoscopy and symptoms of intestinal blood loss or unexplained anemia. In approximately two-thirds of these cases, capsule endoscopy (CE) detects a lesion within the small bowel that explains the patient's symptoms.
The case of an 80-year-old female patient with recurrent melena and anemia is presented here by the authors. Endoscopy of the upper gastrointestinal tract as well as ileocolonoscopy did not show any pathological findings. CE revealed an area with abnormal mucosa in the middle third of the small bowel, which was strongly suspected of having malignant origin. Surgical exploration led to resection of a small jejunal segment with a palpable mass and increased blood flow. Surprisingly, the final diagnosis determined by the pathologist was arteriovenous malformation (AVM). This article is part of an expert video encyclopedia.
The small intestine is a part of the gastrointestinal tract in which digestion and absorption of nutrients takes place. The small bowel follows the stomach and is followed by the large intestine, reaching from the pylorus to the valve of Bauhin and is separated into the duodenum, the jejunum, and the ileum.
Capsule endoscopy (CE) has the potential to offer a perfect overview of the small-bowel mucosa and complete visualization of the entire small bowel is achieved in most cases. In this video, there is an overview offered on normal findings in small-bowel CE and typical anatomical landmarks are indicated. This article is part of an expert video encyclopedia.
This is the case report of a 58-year-old male patient who presented with recurring abdominal pain of 4 months duration. He had undergone multiple investigations including upper and lower gastrointestinal tract endoscopies and diagnostic laparoscopy, but there were no significant findings detected.
Capsule endoscopy revealed a submucosal small bowel tumor that was suspected to originate from the distal third of the small bowel. Surgery was indicated and a highly differentiated neuroendocrine tumor was found at laparotomy at the distal ileum. An ileocecal resection was performed confirming a neuroendocrine tumor of the small bowel (G2T2N1M1). This article is part of an expert video encyclopedia.
In this article, the video demonstrated is an example of a 76-year-old male patient who presented with recurrent intestinal bleeding of unknown origin at the university hospital. Previously performed upper and lower gastrointestinal tract endoscopy did not reveal a bleeding lesion. Capsule endoscopy revealed small-bowel angiectasia that were treated by argon plasma coagulation at subsequent balloon enteroscopy. This article is part of an expert video encyclopedia.
Small bowel varices may be found in less than 5% of patients with suspected small bowel bleeding. These varices are associated with portal hypertension or thrombosis of mesenteric venous vessels and with altered abdominal vascular anatomy with or without prior small bowel surgery. In bleeding small bowel varices, therapeutic options include endoscopic injection of tissue adhesives, endovascular approaches such as balloon-occluded retrograde transvenous or percutaneous obliteration and transjugular intrahepatic portosystemic shunt, and surgical resection. This is a case report of a 53-year-old patient with ethylic liver cirrhosis who presented with severe, life-threatening hematochezia due to small bowel varices. This article is part of an expert video encyclopedia.
This is an example of capsule endoscopy (CE) revealing terminal ileitis in an young male patient with recurrent abdominal pain who had previously been investigated with colonoscopy and esophagogastroduodenoscopy without any significant findings. CE revealed severe inflammation of the terminal ileum. This article is part of an expert video encyclopedia.
Operatively altered anatomy such as Billroth II gastroenterostomy represents a challenge in endoscopic retrograde cholangiopancreatography and might require dedicated instruments. In this article, the authors demonstrate the technique of endoscopic retrograde cholangiography and sphincterotomy in a patient with Billroth's operation-II. Sphincterotomy is performed with a specially designed Billroth papillotome to enable papillotomy in the direction of the papillary roof. This article is part of an expert video encyclopedia.
Here the authors report the case of an elderly woman who had upper abdominal pain, upper gastrointestinal hemorrhage, and jaundice (a symptomatic triad termed the ‘Quincke’ triad) a few days after endoscopic sphincterotomy. Abdominal ultrasonography demonstrated an echo-rich filling of the choledochus consistent with hemobilia. Endoscopic retrograde cholangiography was immediately performed and blood clots were removed from the common bile duct. A nasobiliary catheter was placed to irrigate the bile duct for prevention of recurring obstruction of the bile ducts from blood clots. Further follow-up of the patient was uneventful. This article is part of an expert video encyclopedia.