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Is the capsule a guiding
star ?
Dr. Niv Eva
Department of Gastroenterology
Tel-Aviv Sourasky Medical Center
First Case
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
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
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)
• Ileo-colonoscopy– normal
• Normal biopsies from colon and terminal
ileum
• Video capsule endoscopy (another medical center)
Normal Small Intestinal Mucosa.
Revision of the film…
Normal small intestinal mucosa
What is the diagnosis of the patient ?
Scalloped folds, lack of villi, mosaic pattern
Diagnosis—
Celiac disease
DD: Lymphoma,
Mastocytosis,
Eosinophilic gastroenteritis,
Hypogammaglobulinemia,
Giardiasis,
Tropical sprue
Enteroscopy
Anti TTG positive (high titer)
The diagnosis of celiac disease was established
The mystery was resolved:
• No evidence of Crohn’s disease
• The recent deterioration was explained by wheatbased diet
• Celiac disease is a known cause of
intussusception
Gluten-free diet was started with
quick improvement
The possibility of T cell lymphoma was excluded
Folow up in 10 months
• The patient adheres to gluten-free diet
• The patient is asymptomatic
• Normal nutritional state, normal blood
tests
Summary of First Case
• In this case capsule endoscopy was a
blessing by finding the right diagnosis
when other imaging tests were
misleading.
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
Second Case
•
•
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•
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)
During the following 6 months–
Recurrent episodes of small intestinal
obstruction
Conservative treatment
CT abdomen–
Thickening and mild dilation of
mid-small intestinal loop
•On the basis of clinical picture surgery
was planned
•But the surgeon asked to perform
capsule endoscopy first
Small submucosal lesion
Discrete areas of inflammation
and erosions
Stricturing ulcers
What is the differential diagnosis of
the patient ?
What should be the strategy ?
DD
•
•
•
•
•
Crohn’s disease
NSAIDs or other medications
Lymphoma
TB
Ischemia due to atherosclerosis
or intermittent intussusception (submucosal
tumors, adhesions)
• Ulcerative jejunoileitis
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
The dilemma:
To operate or to give empirical
treatment
Decision– prednisone trial
prednisone 40 mgx1 for 2 weeks—failure
Tapering down
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
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
Follow up in 6 months
• The patient is asymptomatic
• No additional events of small bowel
obstruction
Summary of Second Case
• In this case capsule endoscopy delayed
the definitive treatment (operation) by
several months
Thank you for your attention