Non-small bowel lesion detection at small bowel capsule endoscopy: A comprehensive literature review

Small bowel capsule endoscopy is a minimally-invasive endoscopic investigation that is often used in clinical practice to investigate overt or occult gastrointestinal(GI) bleeding among other clinical indications. International guidance recommends small bowel capsule endoscopy as a first-line investigation to detect abnormalities in the small bowel, when gastroscopy and colonoscopy fail to identify a cause of GI bleeding. It can diagnose with accuracy abnormalities in the small bowel. However, there has been increasing evidence indicating that small bowel capsule endoscopy may also detect lesions outside the small intestine that are within the reach of conventional endoscopy and have been probably missed during prior endoscopic investigations. Such lesions vary from vascular deformities to malignancy and their detection often alters patient management, leading to further endoscopic and/or surgical interventions. The current study attempts to review all available studies in the literature and summarise their relevant findings.

Small bowel ulcerative lesions are common in elderly NSAIDs users with peptic ulcer bleeding

AIM: To determine the frequency of small bowel ulcerative lesions in patients with peptic ulcer and define the significance of those lesions. METHODS: In our prospective study, 60 consecutive elderly patients with upper gastrointestinal bleeding from a peptic ulceration(cases) and 60 matched patients with a non-bleeding peptic ulcer(controls) underwent small bowel capsule endoscopy, after a negative colonoscopy(compulsory in our institution). Controls were evaluated for non-bleeding indications. Known or suspected chronic inflammatory conditions and medication that could harm the gut were excluded. During capsule endoscopy, small bowel ulcerative lesions were counted thoroughly and classified according to Graham classification. Other small bowellesions were also recorded. Peptic ulcer bleeding was controlled endoscopically, when adequate, proton pump inhibitors were started in both cases and controls, and Helicobacter pylori eradicated whenever present. Both cases and controls were followed up for a year. In case of bleeding recurrence upper gastrointestinal endoscopy was repeated and whenever it remained unexplained it was followed by repeat colonoscopy and capsule endoscopy.RESULTS: Forty(67%) cases and 18(30%) controls presented small bowel erosions(P = 0.0001), while 22(37%) cases and 4(8%) controls presented small bowel ulcers(P < 0.0001). Among non-steroidal antiinflammatory drug(NSAID) consumers, 39(95%) cases and 17(33%) controls presented small bowel erosions(P < 0.0001), while 22(55%) cases and 4(10%) controls presented small bowel ulcers(P < 0.0001). Small bowel ulcerative lesions were infrequent among patients not consuming NSAIDs. Mean entry hemoglobin was 9.3(SD = 1.4) g/d L in cases with small bowel ulcerative lesions and 10.5(SD = 1.3) g/dL in those without(P = 0.002). Cases with small bowel ulcers necessitate more units of packed red blood cells. During their hospitalization, 6(27%) cases with small bowel ulcers presented bleeding recurrence most possibly attributed to small bowel ulcers, nevertheless 30-d mortality was zero. Presence of chronic obstructive lung disease and diabetes was related with unexplained recurrence of hemorrhage in logistic regression analysis, while absence of small bowel ulcers was protective(relative risk 0.13, P = 0.05).CONCLUSION: Among NSAID consumers, more bleeders than non-bleeders with peptic ulcers present small bowel ulcers; lesions related to more severe bleeding and unexplained episodes of bleeding recurrence.

Angiodysplasia Presenting with Multiple Polypoid Lesions: An Unusual Cause of Small Bowel Obstruction

Angiodysplasia (AD), a morphologic vascular abnormality, is a common cause of gastrointestinal bleeding. We present a rare case of polypoid AD lesions. Three years after treatment for adhesive bowel obstruction, a 57-year-old man was admitted with recurrent abdominal distension, anorexia, and lower extremity edema. Computed tomography showed his dilated proximal and collapsed distal small bowel loops had disparate calibers. The transition point demonstrated mucosal enhancement and mesenteric lymphadenopathy. We observed small intestinal wall outpouching with strong mucosal enhancement and polypoid lesions dotting the dilated intestine. Intraoperative findings revealed a hard but elastic intraluminal nodule causing small bowel obstruction and the outpouching’s occurrence on the ileum’s antimesenteric border. We performed partial resection of the small intestine involving the nodule and Meckel’s diverticulum. Macroscopically, the nodule, diverticulum, and intestinal mucosa had polypoid lesions. Histopathologically, these lesions had foci within dilated thin- or thick-walled vascular channels in the submucosa, without specific histological abnormalities. These features led to a diagnosis of AD.

Uncovering the uncertainty: Risk factors and clinical relevance of P1 lesions on small bowel capsule endoscopy of anemic patients

AIM To identify risk factors for P1 lesions on small bowel capsule endoscopy(SBCE) and to describe the natural history of anemic patients with such type of lesions.METHODS One hundred patients were consecutively selected for a case-control analysis performed between 37 cases with P1 lesions and 63 controls with negative SBCE. Age, gender, comorbidities and regular medication were collected. Rebleeding, further investigational studies and death were also analyzed during the follow-up.RESULTS No significant differences on gender, median age or Charlson index were found between groups. Although no differences were found on the use of proton pump inhibitors, acetylsalicylic acid, anticoagulants or antiplatelet agents, the use of non-steroidal antiinflammatory drugs(NSAID) was associated with a higher risk of P1 lesions(OR = 12.00, 95%CI: 1.38-104.1). From the 87 patients followed at our center, 39 were submitted to additional studies for investigation of iron-deficiency anemia(IDA), and this was significantly more common in those patients with no findings on SBCE(53.7% vs 30.3%, P = 0.033). A total of 29 patients had at least one rebleeding or IDA recurrence episode and 9 patients died of non-anemia related causes but no differences were found between cases and controls.CONCLUSION P1 lesions are commonly found in patients with IDA submitted to SBCE. The use of NSAID seems to be a risk factor for P1 lesions. The outcomes of patients with P1 lesions do not differ significantly from those with P0 lesions or normal SBCE.

基于Swin Transformer网络与Adapt-RandAugment数据增强方法的小肠胶囊内镜图像分类方法研究

目的:为提高小肠病变分类识别的准确性,提出一种基于Swin Transformer网络与Adapt-RandAugment数据增强方法的小肠胶囊内镜图像分类方法。方法:基于RandAugment数据增强子策略和增强小肠胶囊内镜图像时不丢失特征、不失真的原则提出Adapt-RandAugment数据增强方法。在公开的小肠胶囊内镜图像Kvasir-Capsule数据集中,基于Swin Transformer网络,采用Adapt-RandAugment数据增强方法进行训练,以卷积神经网络ResNet152、DenseNet161为基准,验证Swin Transformer网络和Adapt-RandAugment数据增强方法组合对小肠胶囊内镜图像分类识别的性能。结果:提出的方法宏平均精度(macro average precision,MAC-PRE)、宏平均召回率(macro average recall,MAC-REC)、宏F1分数(macro average F1 score,MAC-F1-S)分别为0.3832、0.3148、0.2905,微平均精度(micro average precision,MIC-PRE)、微平均召回率(micro average recall,MIC-REC)、微平均F1分数(micro average F1 score,MIC-F1-S)均为0.7553,马修斯相关系数(Matthews correlation coefficient,MCC)为0.4523,均优于ResNet152和DenseNet161网络。结论:基于Swin Transformer网络与Adapt-RandAugment数据增强方法的小肠胶囊内镜图像分类方法具有较好的小肠胶囊内镜图像分类识别效果和较高的识别准确率。

Bleeding Dieulafoy's-like lesions of the gut identified by capsule endoscopy

Dieulafoy's-like lesions (DLs-like) represent a cause of obscure gastrointestinal bleeding, enteroscopy being the main diagnostic and therapeutic procedure. Frequently, more than one enteroscopy is needed to identify the bleeding vessel. In our practice, video capsule endoscopy (VCE) identified and guided therapy in four cases of DLs-like; three of them were localized on the small bowel. We report, for the first time, a diagnosis of colonic DL-like performed by colon capsule endoscopy. Two patients presented with severe cardiovascular disorders, being hemodynamically unstable during VCE examination. Based on the VCE findings, only one invasive therapeutic procedure per patient was necessary to achieve hemostasis. VCE and enteroscopy may be regarded as complementary procedures in patients with gut DLs-like.

小肠CTE在炎性肠病及小肠肿瘤早期病变诊断中的应用价值讨论

目的研究小肠CT造影(CTE)在炎性肠病及小肠肿瘤早期病变诊断中的作用。方法回顾性分析122例疑似炎性肠病和小肠肿瘤早期病变患者的临床资料,所有患者均进行小肠CTE检查,并获取病理组织。以病理诊断作为金标准,对比小肠CTE与病理诊断对炎性肠病和小肠肿瘤早期病变的检出率,分析小肠CTE对炎性肠病和小肠肿瘤早期病变的诊断效能。结果病理检出炎性肠病89例,小肠肿瘤早期病变27例,十二指肠溃疡3例,肠息肉3例;小肠CTE检出炎性肠病86例,小肠肿瘤早期病变25例。小肠CTE对炎性肠病和小肠肿瘤早期病变的检出率与病理诊断对比,差异无统计学意义(P>0.05)。小肠CTE诊断炎性肠病的阳性预测值、阴性预测值、敏感度、特异度、准确度、约登指数、误诊率、漏诊率分别为97.67%、86.11%、94.38%、93.94%、94.26%、0.8832、6.06%、5.62%;小肠CTE诊断小肠肿瘤早期病变的阳性预测值、阴性预测值、敏感度、特异度、准确度、约登指数、误诊率、漏诊率分别为96.00%、96.91%、88.89%、98.95%、96.72%、0.8784、1.05%、11.11%。结论通过小肠CTE对炎性肠病和小肠肿瘤早期病变进行诊断能够发挥良好的诊断作用,可以为临床诊断和治疗提供科学的参考。

多层螺旋CT小肠造影对小肠疾病诊断价值的研究

目的分析各类小肠疾病在多层螺旋CT小肠造影(MSCTE)的影像特征。讨论MSCTE的具体操作过程及诊断价值。方法回顾性分析64例行MSCTE检查患者的具体操作过程,结合病理结果,总结各种小肠病变的影像学特征。结果 64例患者中总体阳性率为76.6%(49/64),其中小肠间质瘤3例、腺瘤3例、脂肪瘤1例、腺癌2例、淋巴瘤1例、克罗恩病5例、嗜酸性胃肠炎2例、小肠息肉13例、小肠憩室13例、小肠血管畸形6例。结论 MSCTE对于各类小肠疾病的诊断有重要的价值,有利于小肠病变的定性、分期,为临床医师的后继治疗工作提供依据。

Sensitivity and inter-observer variability for capsule endoscopy image analysis in a cohort of novice readers

AIM： To determine the performance of novice readers （4^th year medical students） for detecting capsule endoscopy findings. METHODS： Ten capsule endoscopy cases of small bowel lesions were administered to the readers. Gold standard findings were pre-defined by gastroenterologists. Ten gold standard ＂targets＂ were identified among the 10 cases. Readers were given a 30-min overview of Rapid Reader software and instructed to mark any potential areas of abnormalities. A software program was developed using SAS to analyze the thumbnailed findings. RESULTS： The overall sensitivity for detecting the gold standard findings was 80%. As a group, at least 5 out of 10 readers detected each gold standard finding per recording. All the gold standard targets were identified when the readers＇ results were combined. Incidental finding/false positive rate ranged between 8.2-59.8 per reader. CONCLUSION： A panel of medical students with minimal endoscopic experience can achieve high sensitivity in detecting lesions on capsule endoscopy. A group of novice readers can pre-screen recordings to thumbnail potential areas of small bowel lesions for further review. These thumbnails must be reviewed to determine the clinical relevance. Further studies are ongoing to assess other cohorts.

小肠胶囊内镜在克罗恩病诊断和治疗中的应用进展

克罗恩病(CD)具有跳跃性、透壁性全消化道炎症的特点。目前内镜、CT肠道造影(CTE)、磁共振肠道造影(MRE)是辅助CD诊断的一线检查手段,但由于小肠特殊的解剖结构,使传统内镜检查受限。MRE、CTE仅对肠壁炎症较敏感,而对小肠黏膜面炎症不敏感,导致小肠CD不易获得早期诊断和治疗。小肠胶囊内镜(SBCE)的问世解决了这一问题。本文就SBCE在CD诊断和治疗中的应用进展作一综述。

多层螺旋CT在小肠疾病中的应用

目的:探讨多层螺旋CT(MSCT)对小肠病变的诊断价值。方法:对34例疑有小肠病变的患者行多层螺旋CT平扫及增强检查。检查前清洁肠道,肌注盐酸山莨菪碱10～20mg以减少肠蠕动,口服足量2.5%等渗甘露醇水对比剂充盈肠管后扫描,结合多平面容积重建(MPVR)和/或最大密度投影(MIP)后处理观察图像。结果:正常12例;病变22例,均经手术病理证实:小肠肿瘤12例,其中间质瘤4例(良性1例,恶性3例),淋巴瘤2例,腺癌3例,腺瘤2例和脂肪瘤1例;Crohn病3例;术后粘连性肠梗阻3例;肠系膜扭转后梗阻2例;肠系膜上动脉栓塞1例;增生性肠结核1例。结论:多层螺旋CT对小肠病变的定位、定性、肿瘤分期、肠系膜及其血管病变有较高临床价值,是诊断小肠疾病的重要方法。

Ileal polypoid lymphangiectasia bleeding diagnosed and treated by double balloon enteroscopy

Intestinal lymphangiectasia is a rare disease characterized by focal or diffuse dilated enteric lymphatics with impaired lymph drainage.It causes protein-losing enteropathy and may lead to gastrointestinal bleeding.Commonly,lymphangiectasia presents as whitish spots or specks.To our knowledge,small bowel bleeding resulting from polypoid intestinal lymphangiectasia has not been reported.Here,we report a rare case of active bleeding from the small bowel caused by polypoid lymphangiectasia with a review of the relevant literature.An 80-year-old woman was hospitalized for melena.Esophagogastroduodenoscopy could not identify the source of bleeding.Subsequent colonoscopy showed fresh bloody material gushing from the small bowel.An abdominal-pelvic contrast-enhanced computed tomography scan did not reveal any abnormal findings.Video capsule endoscopy showed evidence of active and recent bleeding in the ileum.To localize the bleeding site,we performed double balloon enteroscopy by the anal approach.A small,bleeding,polypoid lesion was found in the distal ileum and was successfully removed using endoscopic snare electrocautery.

多层螺旋CT小肠造影对小肠病变的临床应用研究

目的分析对小肠病变患者实施多层螺旋CT小肠造影检查的临床价值。方法选取2015年10月—2017年5月收治的45例小肠病变患者作为研究对象,进行多层螺旋CT小肠造影检查,同时与手术病理结果进行对比,分析对多层螺旋CT小肠造影的临床诊断准确率。结果诊断后,45例患者中多层螺旋CT小肠造影检查检出阳性病灶率86.67%(39/45),不明消化道出血病变检出率为85%(17/20),腹痛病变检出率为100%(13/13),小肠癌75%(9/12),与手术病理对比无显著差异(P>0.05)。结论通过多层螺旋CT小肠造影对小肠病变部位、范围及性质作出全面的评价,可为临床诊断及治疗提供可靠的依据,有利于患者的早期治疗,值得临床推广。

64层螺旋CT诊断小肠出血性疾病的价值分析

目的:分析64层螺旋CT诊断小肠出血性疾病的价值情况。方法:选择2017年9月~2018年9月来本院接受治疗的小肠出血者88例为研究对象,对其开展64层螺旋CT检查,分析结果。结果:38例为十二指肠间质瘤。其中水平部共计14例,肠降部24例。十二指肠乳头癌共计16例。肠间质瘤共计12例,回肠淋巴瘤共计6例,回肠盲部外伤性出血共计2例,阳性率为84.1%(74/88)。结论:针对于小肠出血者来讲,利用64层螺旋CT开展诊断能够取得较为满意的临床效果。其有着安全性强、可靠性高的特征。