is the capsule a guiding star ? dr. niv eva department of gastroenterology tel-aviv sourasky medical...
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Is the capsule a guiding star ?
Dr. Niv EvaDepartment of Gastroenterology
Tel-Aviv Sourasky Medical Center
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First Case
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44 y.o. woman
13 years agoAbdominal pain, diarrheaNormal 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 stopped5ASA, prednisone– good responseRecently asymptomatic all medications stopped
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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
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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)
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• Ileo-colonoscopy– normal
• Normal biopsies from colon and terminal ileum
• Video capsule endoscopy (another medical center)
Normal Small Intestinal Mucosa.
Revision of the film …
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Normal small intestinal mucosa
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What is the diagnosis of the patient?
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Scalloped folds, lack of villi, mosaic patternDiagnosis—
Celiac disease
DD: Lymphoma, Mastocytosis, Eosinophilic gastroenteritis, Hypogammaglobulinemia, Giardiasis, Tropical sprue
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Enteroscopy
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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
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Folow up in 10 months
• The patient adheres to gluten-free diet • The patient is asymptomatic• Normal nutritional state, normal blood
tests
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Summary of First Case
• In this case capsule endoscopy was a blessing by finding the right diagnosis when other imaging tests were misleading.
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Endoscopy 2005ICCE 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 disease2. Initial diagnosis in patient with positive celiac
serology who is unwilling or unable to undergo EGD
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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)
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During the following 6 months–
Recurrent episodes of small intestinal obstruction
Conservative treatment
CT abdomen– Thickening and mild dilation of mid-small intestinal loop
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•On the basis of clinical picture surgery was planned
•But the surgeon asked to perform capsule endoscopy first
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Small submucosal lesion
Discrete areas of inflammation and erosions
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Stricturing ulcers
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What is the differential diagnosis of the patient?
What should be the strategy?
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DD
• Crohn’s disease
• NSAIDs or other medications
• Lymphoma
• TB
• Ischemia due to atherosclerosis
or intermittent intussusception (submucosal tumors, adhesions)
• Ulcerative jejunoileitis
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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
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The dilemma:
To operate or to give empirical treatment
Decision– prednisone trialprednisone 40 mgx1 for 2 weeks—failureTapering down
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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
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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
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Follow up in 6 months
• The patient is asymptomatic
• No additional events of small bowel obstruction
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Summary of Second Case
• In this case capsule endoscopy delayed the definitive treatment (operation) by several months
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Thank you for your attention