capsule endoscopy in tamworth. true or false: “capsule endoscopy is a useful test in the diagnosis...
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Capsule Capsule EndoscopyEndoscopy
in Tamworth in Tamworth
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True or False: True or False: “Capsule “Capsule
Endoscopy is a Endoscopy is a useful test in the useful test in the
diagnosis of diagnosis of unexplained unexplained
anaemia”anaemia”FALSEFALSE
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Importance of Pre Test Importance of Pre Test ProbabilityProbability
MBS – Item Number 11820MBS – Item Number 11820 obscure gastrointestinal bleedingobscure gastrointestinal bleeding, using a capsule endoscopy , using a capsule endoscopy
device approved by the Therapeutic Goods Administration (including device approved by the Therapeutic Goods Administration (including administration of the capsule, imaging, image reading and interpretation, administration of the capsule, imaging, image reading and interpretation, and all attendances for providing the service on the day the capsule is and all attendances for providing the service on the day the capsule is administered), (not being a service associated with double balloon administered), (not being a service associated with double balloon enteroscopy), if: enteroscopy), if: (a) the service is performed by a specialist or consultant physician (a) the service is performed by a specialist or consultant physician
with endoscopic training that is recognised by The Conjoint with endoscopic training that is recognised by The Conjoint Committee for the Recognition of Training in Gastrointestinal Committee for the Recognition of Training in Gastrointestinal Endoscopy; and Endoscopy; and
(b) the patient to whom the service is provided: (b) the patient to whom the service is provided: (i) is aged 10 years or over; and (i) is aged 10 years or over; and (ii) has (ii) has recurrent or persistent bleedingrecurrent or persistent bleeding; and ; and (iii) is (iii) is anaemic or has active bleedinganaemic or has active bleeding; and ; and
(c) an (c) an upper gastrointestinal endoscopy and a upper gastrointestinal endoscopy and a colonoscopy have been performed on the patient and colonoscopy have been performed on the patient and have not identified the cause of the bleedinghave not identified the cause of the bleeding; and ; and
(d) (d) the service is performed within 6 months of the the service is performed within 6 months of the upper gastrointestinal endoscopy and colonoscopyupper gastrointestinal endoscopy and colonoscopy
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Understanding the “O’s” of Understanding the “O’s” of GI BleedingGI Bleeding
ObscureObscure Cause not identified after endoscopies Cause not identified after endoscopies
(up to10% - 75% will be due to small bowel lesions)(up to10% - 75% will be due to small bowel lesions)
OvertOvert Melaena or haematocheziaMelaena or haematochezia
OccultOccult Not OvertNot Overt
In practice, obscure GI bleeding is eitherovert or causes iron deficiency
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Diagnosing Iron Diagnosing Iron DeficiencyDeficiencyIron Iron
DeficiencDeficiencyy
Systemic Systemic DiseaseDisease
MixedMixed
IronIron ↓↓ ↓↓ ↓↓TransferriTransferrinn
↑↑ ↓↓ ↓↓
TransferriTransferrin n SaturationSaturation
↓ ↓↓ ↓ ↓ ↓ / N / ↑/ N / ↑ ↓↓
FerritinFerritin ↓ ↓ ↑↑ ↓ ↓ / N / ↑/ N / ↑TransferriTransferrin Receptorn Receptor
↑↑ NN ↑↑
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Initial Iron Deficiency Initial Iron Deficiency WorkupWorkup
Consider ExtraIntestinal CausesConsider ExtraIntestinal Causes DietaryDietary Pregnancy, LactationPregnancy, Lactation MenstruationMenstruation HaemolysisHaemolysis Blood donationBlood donation HaematuriaHaematuria
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Initial Iron Deficiency Initial Iron Deficiency WorkupWorkup
Consider ExtraIntestinal CausesConsider ExtraIntestinal Causes GastroscopyGastroscopy
Ulcers, Malignancy, Angioectasia, GAVEUlcers, Malignancy, Angioectasia, GAVE H. Pylori H. Pylori statusstatus Duodenal biopsies for coeliac diseaseDuodenal biopsies for coeliac disease
ColonoscopyColonoscopy Malignancy, colitis, angioectasia, Malignancy, colitis, angioectasia,
proctitisproctitis Include ileoscopyInclude ileoscopy Good bowel preparation importantGood bowel preparation important
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Initial Iron Deficiency Initial Iron Deficiency WorkupWorkup
If Endoscopies are non-diagnostic:If Endoscopies are non-diagnostic: Reconsider extraintestinal causesReconsider extraintestinal causes Consider Urinalysis and Coeliac disease Consider Urinalysis and Coeliac disease
serologyserology
Iron Replacement OR Early Capsule Iron Replacement OR Early Capsule EndoscopyEndoscopy
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Iron Replacement OR Iron Replacement OR Early Capsule EndoscopyEarly Capsule Endoscopy
Iron ReplacementIron Replacement YoungerYounger PremenopausalPremenopausal AsymptomaticAsymptomatic Never overt bleedingNever overt bleeding
Observe for at least 3 Observe for at least 3 months then recheck months then recheck Hb and ferritin. If Hb and ferritin. If “recurrent or persistent “recurrent or persistent bleeding”, then capsule bleeding”, then capsule endoscopyendoscopy
Early Capsule Early Capsule EndoscopyEndoscopy OlderOlder MaleMale Symptoms, Weight lossSymptoms, Weight loss Any overt bleedingAny overt bleeding
Need to demonstrate Need to demonstrate “recurrent or persistent “recurrent or persistent bleeding” – eg 2 low bleeding” – eg 2 low Hb’s, a positive FOBT Hb’s, a positive FOBT after endoscopies etcafter endoscopies etc
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Capsule Endoscopy Capsule Endoscopy PreparationPreparation
Similar to colonoscopySimilar to colonoscopy Stop iron tablets 5 days priorStop iron tablets 5 days prior Clear fluids afternoon beforeClear fluids afternoon before 2 sachets of PicoPrep2 sachets of PicoPrep 10 hour fast10 hour fast
On the dayOn the day Metoclopramide and simethiconeMetoclopramide and simethicone
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What Does Capsule Endoscopy What Does Capsule Endoscopy Visualize in the Small Bowel?Visualize in the Small Bowel?
Melanoma Inflammation by infection (eg, CMV)
Angioectasia Inflammatory stenosis
Overt bleeding Mass/tumor Ulcerated stenosis caused by NSAID use
Bleeding ulcer
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Yield of Capsule Yield of Capsule EndoscopyEndoscopy
38 – 83%38 – 83% Depends largely on pre test Depends largely on pre test
probabilityprobability Of small bowel lesions found:Of small bowel lesions found:
60% angioectasia60% angioectasia 30% ulcers / erosions30% ulcers / erosions 10% tumours10% tumours
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Other Diagnostic OptionsOther Diagnostic Options
MethodMethod Diagnostic YieldDiagnostic Yield ConsiderationsConsiderations
Standard Standard Radiological ImagingRadiological Imaging
• Low: 5% (unable to Low: 5% (unable to diagnose most vascular diagnose most vascular lesions)lesions)
• Impact on management: <10%Impact on management: <10%•Useful for clinical suspicion of small bowel Useful for clinical suspicion of small bowel obstruction, tumorsobstruction, tumors
Bleeding ScanBleeding Scan• Low: ~25%Low: ~25%• Location accuracy:Location accuracy: ~30–50% ~30–50%
• Sensitivity threshold: 0.3 mL/minSensitivity threshold: 0.3 mL/min• Prerequisite to angiographyPrerequisite to angiography• Time-consumingTime-consuming• Little or no benefit in typical OGIBLittle or no benefit in typical OGIB
AngiographyAngiography • Low: 25%–30%Low: 25%–30%• Sensitivity threshold: 0.5 mL/hSensitivity threshold: 0.5 mL/h• InvasiveInvasive• Identifies bleeding/non-bleedingIdentifies bleeding/non-bleeding lesions lesions
Double-Balloon Double-Balloon EnteroscopyEnteroscopy • 60%–80%60%–80%
• Time-consumingTime-consuming• Requires extensive training; additional Requires extensive training; additional nursing staff, anesthesiological support often nursing staff, anesthesiological support often requiredrequired• Optimal patient selection requiredOptimal patient selection required
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Diagnostic Options Diagnostic Options (continued)(continued)
MethodMethod Diagnostic YieldDiagnostic Yield ConsiderationsConsiderations
Intraoperative Intraoperative EnteroscopyEnteroscopy
• 70%–100%70%–100% • Transfusion-dependent (severe blood loss)Transfusion-dependent (severe blood loss)
• Risk of continued bleeding (outweighs risk of therapy)Risk of continued bleeding (outweighs risk of therapy)
• Technically difficultTechnically difficult
• Adhesions, luminal blood, infiltrating neoplasiaAdhesions, luminal blood, infiltrating neoplasia
• Complications (during and after procedure)Complications (during and after procedure)
CT Enterography CT Enterography • Low: vascular Low: vascular malformations, malformations, ulcerative diseaseulcerative disease
• ~20% of submucosal lesions missed~20% of submucosal lesions missed
Push Push Enteroscopy Enteroscopy
• 15%–35% average15%–35% average
• Variable for overt Variable for overt bleeding and AVMs: bleeding and AVMs: 5%–65% 5%–65%
• May detect missed proximal lesionsMay detect missed proximal lesions
• Provides opportunity to identify and treat active Provides opportunity to identify and treat active bleeding (AVMs only) 25%– 85% of the time within a bleeding (AVMs only) 25%– 85% of the time within a single yearsingle year
Small Bowel CESmall Bowel CE • 38%–83%38%–83% • Affects change in management in ≥87% of patients Affects change in management in ≥87% of patients (50%–66% remain transfusion-free)(50%–66% remain transfusion-free)
• Low re-bleeding rates in patients with negative findings Low re-bleeding rates in patients with negative findings of CE (5.6%–11%)of CE (5.6%–11%)
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Complications Of Capsule Complications Of Capsule EndoscopyEndoscopy
Failure to enter the small bowelFailure to enter the small bowel Dyspahgia, GastroparesisDyspahgia, Gastroparesis Can insert endoscopicallyCan insert endoscopically
Failure to visualise all small bowelFailure to visualise all small bowel 10-16%10-16% DiabeticsDiabetics
Capsule RetentionCapsule Retention <1% for OGIB, up to 10% for Crohn’s disease<1% for OGIB, up to 10% for Crohn’s disease Caution with previous small bowel surgery or Caution with previous small bowel surgery or
abdominal radiotherapy or clinical suspicion of abdominal radiotherapy or clinical suspicion of obstructionobstruction
DBE or surgery to remove capsule +/- resect DBE or surgery to remove capsule +/- resect lesionlesion
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What to do with the What to do with the ResultResult
NegativeNegative : Observe unless symptoms : Observe unless symptoms suggest further investigationsuggest further investigation
TumoursTumours : Consider resection : Consider resection UlcersUlcers : Stop aspirin/NSAIDs, consider : Stop aspirin/NSAIDs, consider
Crohn’s diseaseCrohn’s disease AngioectasiaAngioectasia : :
Reassurance and Iron Replacement (safest)Reassurance and Iron Replacement (safest) Assess antiplatelet agents or anticoagulantsAssess antiplatelet agents or anticoagulants If not controlled with iron, or intolerant of If not controlled with iron, or intolerant of
iron, then consider ablative therapyiron, then consider ablative therapy
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Via Gastroscopy, Enteroscopy
or Colonoscopy
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Patient Histology Capsule Endoscopy Quartile
Surgical Quartile
1 Carcinoid 4 4
2 Adenocarcinoma 4 4
3 Adenocarcinoma 1 1
4 Gastrointestinal Stromal Tumour
3 2
5 Adenocarcinoma 1 1
6 Cavernous Haemangioma
2 3
7 Lymphoma 1 1
8 Gastrointestinal Stromal Tumour
3 2
9 Adenocarcinoma 4 4
10 Gastrointestinal Stromal Tumour
2 1
11 Hyperplastic polyp 1 1
12 Cavernous Haemangioma
3 2
13 Ectopic Pancreas 3 2
Identical quartile in 7/13Different quartile by one in 6/13
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324
105
58
104
57 57
1610 15
28
5 2 1 2
47
164
0
50
100
150
200
250
300
350
1 2 3 4
Quartile
Nu
mb
er
Angioectasia
Red Spot
Ulcer
Tumour
Anterograde Push Enteroscopy
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Other indications for Small Other indications for Small Bowel Capsule EndoscopyBowel Capsule Endoscopy
Peutz-Jager syndromePeutz-Jager syndrome Crohn’s disease*Crohn’s disease* Coeliac disease*Coeliac disease* Abnormal SB radiology*Abnormal SB radiology*
* Not medicare rebateable* Not medicare rebateable
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Other Types of CapsulesOther Types of Capsules
Patency CapsulePatency Capsule
Oesophageal CapsuleOesophageal Capsule
Colonic capsuleColonic capsule
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So how do I get one?So how do I get one?
Refer for a consultationRefer for a consultation
OROR Fax information across and I can Fax information across and I can
have a lookhave a look
OROR Refer directly yourselfRefer directly yourself
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Questions?Questions?