NEWS - Family docs say capsule endoscopy offers journey to 'last unexplored viscus'

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Family docs say capsule endoscopy offers journey to 'last unexplored viscus'

9/30/2005

By: Shalmali Pal

SAN FRANCISCO - Discovering and diagnosing problems in the small bowel is

hardly smooth sailing. Indirect imaging exams inside the bowels can be

difficult to carry out, cause patient discomfort, and may outright miss

small, mucosal, and flat lesions. Other techniques, such as intraoperative

enteroscopy, are invasive, riskier, and more expensive.

The technology that is charting the right course for small bowel studies is

capsule endoscopy (CE), according to a presentation Wednesday at the

American Academy of Family Physicians (AAFP) meeting.

" The small bowel really has been the last unexplored viscus ... and we're

off in search of a gold standard, " said Dr. Vogel, a family physician

practicing in Rochester, MN.

Currently, only one capsule endoscopy camera (PillCam, Given Imaging,

Yoqneam, Israel) -- also known as wireless CE, video CE, and telemetric

gastrointestinal capsule imaging -- is approved for use in the U.S.

Vogel, and his co-presenter Dr. Sorenson, a gastroenterologist from

Brainerd Medical Center in Brainerd, MN, offered their audience of primary

care physicians a crash course on CE and how the technology can be

incorporated into a general practice. They also discussed how CE was, on the

whole, complementary to traditional imaging.

CE indications

Capsule endoscopy is particularly adept at pinpointing early-stage Crohn's

disease, when changes are mostly mucosal. Early Crohn's disease cannot be

caught with standard workup (inflammatory markers, x-ray, colonoscopy), but

CE can help make the diagnosis in as many as 70% of patients, Vogel said.

Sorenson described a case of a 37-year-old woman with a family history of

Crohn's disease. She presented with severe diarrhea and symptoms of

irritable bowel disease (IBD). Her small bowel follow-through exam was

normal, and her lab screen showed no inflammatory process. However, the CE

exam revealed nodularity, loss of mucosal detail, submucosal ulcers, and

inflammation for a diagnosis of active Crohn's disease.

" A few years ago, we would have had no way to get at that diagnosis, "

Sorenson said. " We saw the areas of cobblestone (nodules), we saw

superficial ulcerations, we saw subepithelial hemorrhage, we saw findings

that were consistent with Crohn's disease.... Capsule endoscopy shows us

things that we haven't been able to see before. "

Because most cases of obscure gastrointestinal bleeds (OGIB) arise from the

sites in the small bowel, it makes sense that CE is becoming part of the

standard workup protocol. The standard workup consists of colonoscopy,

esophagogastroduodenoscopy (EGD), and a barium imaging study. But about 5%

of OGIB remains undiagnosed even after this workup. CE is particularly adept

at identifying the source of ongoing bleeding, particularly in the first 10

days.

Capsule endoscopy can also shed light on NSAID enteropathy. Patients on

extended NSAID usage develop thin, circumferential strictures (diaphragms or

webs) that cannot be identified on x-ray.

While small bowel tumors are not common, CE can spot them early enough to

ensure faster treatment and a better outcome, the authors stated. Vogel

noted that the cause of gastrointestinal bleeding in people younger than age

50 is most likely a tumor.

Finally, CE may prove to have advantages for tracking celiac disease,

detecting villous changes and atrophy, finding parasites, and monitoring

radiation enteritis.

Contraindications

Capsule endoscopy is not recommended in patients with known gastrointestinal

obstructions, strictures, or fistulas. However, these issues can be

circumvented with special procedures, such as placing the CE in the duodenum

endoscopically, the presenters explained.

CE should also be avoided in patients who could not tolerate surgery or are

about to undergo an MRI. The greatest risk associated with CE is a retained

capsule, although this can be a blessing in disguise.

Sorenson described a case in which a 67-year-old woman presented with

ongoing bleeding. Although she had a history of hematochezia and collagenous

colitis, she did not complain of any pain or other symptoms. Her capsule got

stuck in the small bowel, and Sorenson found that a friable, ulcerated

hemorrhagic lesion in the distal ileum was to blame.

Two days later, the woman arrived at the emergency department with acute

abdominal pain. A two-view x-ray and a follow-up CT revealed the capsule

lodged in her small bowel. But it also revealed a heterogenous mass in the

pelvis, which was ultimately diagnosed as ovarian carcinoma.

" We don't know how long she would have gone without symptoms, " Sorenson

said.

" (The capsule) getting stuck is not the worst thing, " Vogel echoed. While

retained capsules can be surgically removed, patients sometimes elect to

leave them in as long as they are not causing discomfort, he said.

Imaging and CE

" (Imaging) and CE are complementary. It's not one or the other, " Vogel said.

If obstruction is a concern, the best pre-CE test is CT enteroclysis.

Obstruction of the capsule in Crohn's disease can be a barrier to CE, but

the exam may proceed if the patient has no signs of obstruction on a small

bowel follow-through x-ray exam, Sorenson said. Vogel added that patients

with prestenotic dilatation are unlikely to properly pass the capsule and

would benefit from another type of test.

Vogel also said that x-ray and ultrasound are complementary for evaluating

the bowel wall and searching for fistulas, masses, and abscesses. While CE

may pick up lesions in the colon, it cannot replace colonoscopy (a common

query that Vogel said he received from patients).

Sorenson offered an example of a case in which CE and imaging worked in

concert. He described a 76-year-old male with severe diarrhea, abdominal

pain, and excessive gas. The patient had a history of Crohn's disease and

small bowel lymphoma, as well as progressive anemia. He was on steroid

therapy.

Abdominal CT and small bowel x-ray showed no obstruction, so Sorenson

proceeded with CE. The latter showed thickening and redness in the distal

ileum. He went on to colonoscopy, which revealed a cytomegalovirus (CMV)

inclusion. The final diagnosis was Crohn's disease complication with CMV

inclusion, enteritis, and colitis, Sorenson said.

Vogel directed the audience to several published articles that have compared

CE to barium small bowel exams, CT, and MR enteroclysis (Abdominal Imaging,

March-April 2005, Vol. 30:2, pp. 179-183; RadioGraphics, May-June 2005, Vol.

25:3, pp. 697-711; Radiology, January 2004, Vol. 230:1, pp. 260-265;

RadioGraphics, October 2001, supplement no. 21, pp. S161-S172).

Patients and payment

Word of mouth about the relative comfort level associated with CE has made

some patients particularly primed for the procedure. " Patients don't like

having some of the other tests that we give them. They do prefer (CE) by a

large margin. Getting patients to say, 'I'll have that EGD done or that

colonoscopy' is not always easy, " Vogel said.

Of course, there are some caveats. Patients need to understand that small

bowel CE is not a screening test, Vogel stressed, and is sometimes best used

in conjunction with other exams, leaving a patient to decide how many tests

he or she is willing to endure. And as with those other exams, patient

preparation is important. That may include fasting or stopping other

medications for at least a week before CE.

Reimbursement for CE is coming along. Medicare and Blue Cross Blue Shield

(of Minnesota) will cover CE for OGIB and Crohn's disease, Vogel said. (For

a list of payors compiled by Given Imaging, click here.)

As with any new technology, CE does require capital outlay. Sorenson

estimated that a total CE exam will run about $1,000, which is similar to a

colonoscopy. Medicare payment for reading a CE exam is around $180, he said.

Each single-use capsule is approximately $450, but the real investment is

the equipment, which may require a $25,000 investment. The presenters urged

attendees to look at it as a worthwhile one. " We need to know what's in the

best interest of our patients. We not only have more scope (with CE), we

have more detail, " Vogel said. " CE can change clinical decisions. "

By Shalmali Pal

AuntMinnie.com staff writer

September 30, 2005

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