Cápsula Endoscopica

Dr. Patricio Ibáñez L.

Departamento de Gastroenterología

Evaluación del Intestino Delgado

• Push Enteroscopy

• CT Enterography

• Small Bowel MRI’s

• Intra-operative enteroscopy

• Double Balloon Enteroscopy

Cápsula

• Diámetro 11mm: Largo 26mm• Domo óptico: Iluminado por (LED’s)• Lente• Color camera chip• Transmisor• 2 baterías (silver oxide)

Características de la Cápsula

oToma 2 imágenes por segundo

oEn promedio se obtienenen 50,000

imágenes (8 h)

oMagnificación: 8x

oRecubrimiento de Cápsula: no-adherente

oDesechable

“Endoscopia fisiológica”

• Intestino es visualizado en su estado normal• No hay “ trauma endoscopico”• No hay insuflación como artefacto

• Se puede hacer bajo anticoaculación

GE Junction Duodenum

Jejunum Ileocecal Valve

Phlebectasia AVM

Lymphangectasia

Bleeding Lesion

Lymphoma

GIST

Polypoid Mass

Polyp

NSAID stricture Radiation Enteritis

Sprue Villous Drop Out

Hallazgos sutiles

• Punteado blanquecino en las vellosidades: Inlamatorio o neoplasico?

• “Q-tip” lesion

                                                                                             

                                                                                            

Inflammatory polyp

Crohn’s disease

Linear Erosions

Ileitis

¿Cómo lo hacemos?

Ayunas noche previa 12 Hr

Se aplican sensores en el paciente

Se instala un cinturón con bateria y grabador (data recorder)

Ingiere la cápsula (8-9 am)

Puede tomar líquidos 2 hrs después

Puede comer después de 4 hr

Evitar estar cerca de otro paciente/cápsula.

Debe volver 7-8 hrs después

Indicaciones

• Sangrado Intestinal de origen oscuro

• Anemia de origen no precisado

• Sospecha de Enfermedad de Crohn

• Sospecha de Enfermedad Celiaca

• Imagen de I Delgado anormal

• Sospecha de malabsorción

• Dolor abdominal sin causa clara

• Vigilancia de polipos en Sd Poliposos

hereditarios

Complicaciones

•Retención : 1-5%

•Obstrucción: 0.5 %

•Aspiración: Raro

Cheifetz AS . Am Journal Gastro 2006

Contraindicaciones

•Absolutas:• Sospecha de obstrucción• Embarazo

•Relativas:• Trastornos de motilidad• Diverticulosis intestino delgado

Consentimiento

• CE no reemplaza evaluación de estómago y

colon

• Riesgo incluye obstrucción (puede requerir

procedimiento para ser retirada)

• No hacer MR hasta que la CE ha pasado

• Puede no verse completo el ID

Tiempo de Tránsito Promedio•Estómago: 1 hra.

• Intestino Delgado: 4 hrs.

•Eliminación de Cápsula: 2-3 días

Cápsula en sangrado GI obscuro• Cápsula presenta mejor rendimiento diagnóstico que:

– Enteroscopia (56 vs 26 %)– E-TAC (78 vs 22%) ; Cápsula + E-TAC 96%– Angiografía

• Tasa de detección aumenta cuando la cápsula es precoz (< 48 hrs)

• Útil para definir sitio de sangrado previo a enteroscopia o cirugía

Endoscopy 2004: 36, 1067–1073.Gastrointest. Endosc. 2011: 73, 1002–

1008.

Aines vs aspirina ?

• Comparison of Small-Bowel Mucosal Injury between Low-Dose Aspirin and Non-Aspirin Non-Steroidal Anti-Inflammatory Drugs: A Capsule Endoscopy Study.

• All patients were found to have small-bowel mucosal injuries on CE. T

• he two groups were compared for the number of small-bowel mucosal injuries and CE

scores on the basis of the findings of CE.

• Conclusion: Small-bowel mucosal injuries were significantly milder in the LDA group than

in the non-aspirin NSAID group, though reddened lesions were more frequent in the LDA

group. © 2014 S. Karger AG, BaseDigestion. 2014 May 22;89(3):225-231.

LDA (78) AINEs (40)

Lesiones 2.49 ± 3.15 1.65 ± 3.04

Ulceras 1.56 ± 3.75 6.08 ± 10.4

Long-term follow-up of patients undergoing capsule and double-balloon enteroscopy for identification and treatment of small-bowel

vascular lesions: a prospective, multicenter study

• Risk of rebleeding after endoscopic therapy for SBVLs detected by video capsule enteroscopy (VCE).

• The secondary aim was to assess risk factors for rebleeding. • A prospective, multicenter study (15 centers) was conducted, involving patients with obscure gastrointestinal bleeding

and SBVL on VCE who were treated during double-balloon enteroscopy (DBE).

• The likelihood of bleeding was defined according to VCE findings, as high or low.

• Results: 183 DBE therapy , and 64 (35 %) had rebleeding during the 1 year follow-up period

• Cardiac disease (hazard ratio [HR] 2.04, 95 % confidence interval [CI] 1.20 - 3.48; P < 0.01)• overt bleeding (HR 1.78, 95 %CI 1.07 - 2.97; P = 0.03) at presentation were associated with the risk of rebleeding. • chronic renal failure and the risk of rebleeding was close to statistical significance (HR 1.77, 95 %CI 0.94 - 3.33; P = 

0.08).• Kaplan-Meier analysis suggested that patients treated during DBE for a lesion with low likelihood of bleeding on VCE

had higher rebleeding rates than those with a high likelihood of bleeding (HR 1.87, 95 %CI 0.94 - 3.37; P = 0.07). • Conclusion: Despite long-term remission in most patients, about one-third had rebleeding at 1 year. Independent risk

factors for rebleeding were cardiac disease and overt bleeding at original presentation. The lesion characteristics on VCE may be useful to evaluate the bleeding potential of the lesion and may be used for better selection of patients for DBE.

Endoscopy. 2014 May 15.

Prior Capsule Endoscopy Improves the Diagnostic and Therapeutic Yield of Single-Balloon Enteroscopy.

retrospective analysis of a prospectively collected database at a tertiary-care academic medical center between 2011 and 2013 for all patients referred for SBE.

RESULTS:150 patients 170 SBE

indications anemia, overt or occult gastrointestinal bleeding, and suspected mass.

CE prior to SBE 113 of 150 patients (75 %). diagnostic yield for small-bowel disease by CE was 62 %. Therapeutic interventions included hemostasis, polypectomy, and foreign body removal. Total diagnostic and therapeutic yield of SBE was 60 and 28 %, respectively. The diagnostic yield of SBE with prior CE was 68 versus 44 % for SBE without prior CE (P 0.002). The therapeutic yield of SBE with prior CE was 35 versus 12 % without prior CE (P 0.001)CONCLUSIONS:SBE appears to be a safe and effective technique for the diagnosis and treatment of small-bowel

disease; however, we recommend performing a CE prior to SBE to improve the diagnostic and therapeutic yield of the procedure.

Digetsive disease and science

.

Cápsula en Crohn

• En Crohn establecido– Detección de más segmentos comprometidos

• En colitis indiferenciada, 15 % de detección de lesiones en ID

• En sospecha de Crohn, mejor rendimiento que otras técnicas (E-TAC, ileocolonoscopia, enteroscopia)– Si calprotectina (-), muy bajo rendimiento

• Riesgo de retención de cápsula Endoscopy 2008; 40, 30–35Am J Gastroenterol. 2010; 105:1240-8Scand J Gastroenterol. 2011;46:561-6

Cápsula en Crohn: pros y cons

Small bowel capsule endoscopy

• Complete visualization of the small bowel mucosa

• Less invasive than conventional endoscopy

High diagnostic yield for small mucosal lesions

• Scores of severity need further validation in larger cohort of patients

No mucosal sampling for histology • Costs

• Recent validation of scores of severity (Niv and Lewis)

• Bowel preparation

• No transmural evaluation

• Not widely available Clin Exp Gastroenterol. 2014 May 20;7:151-161. eCollection 2014.

Fecal calprotectin: a selection tool for small bowel capsule endoscopy in suspected IBD with prior negative bi-directional endoscopy

Fecal calprotectin (FC) is a non-invasive marker of gastrointestinal inflammation with advocated diagnostic precision in distinguishing inflammatory bowel disease (IBD) from non-IBD diagnoses.

To investigate the value of FC as a selection tool for further investigation of the small

• Scand J Gastroenterol. 2011 May;46(5):561-6. doi: 10.3109/00365521.2011.551835. Epub 2011 Jan 27.

Patients referred with clinical suspicion of CD and negative bi-directional endoscopies.

Only patients with FC results prior to the SBCE test were included; in cases of multiple FC determinations, the value closest to the SBCE date was selected.

Medications history including usage of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) was made available for all patients.

SBCE findings were analyzed against final diagnosis and FC values.RESULTS:

72 (53 females, 17 males)

23FC (≤ 50 μg/g) and in all those the SBCE was normal.

44FC >50 μg/g; in this group,

9 51 and 100 μg/g and all had a normal SBCE.

35 >100 μg/g; 15 (42.85%) compatible with FC levels 326 μg/g (range 116-1430 μg/g).

A definitive clinical diagnosis of CD, based on subsequent follow-up, was made in 10/35 (28.5%) of patients.

These 10 patients were within the subgroup of 15 patients with positive SBCE findings and had median FC levels 368 μg/g (range 235-1430 μg/g).CONCLUSIONS:FC >100 μg/g is good predictor of positive SBCE findings, while

FC >200 μg/g was associated with higher SBCE yield (65%) and confirmed CD in 50% of cases.

.

Cápsula en tumores y pólipos ID

• Hallazgo en 2-9% en cápsulas solicitadas por otra causa

• Estudio multicéntrico 5.129– 2.4% tumores (2.2 primarios vs 0.2 metástasis)– 32% GIST, 20% adeno Ca, 15% Carcinoides

• Herramienta útil en detección de pólipos ID en síndromes polipósicos

Endoscopy. 2008;40(6):488-95.

Cápsula en niños

• Aprobada en > 10 años

• Experiencias reportadas en > de 2 años u 11.5 kg– Serie de 70 niños 2 a 10 años, las indicaciones fueron:– 25% Crohn, 24% anemia ferropriva, 14% sangrado oculto,

16% Sd polipósicos, 10% GVH

• Meta análisis 15 estudios, 723 casos < 18 años– Indicaciones 54% EII– Rendimiento 65%– Examen 86% completo, Retención 2.6%

Clin Gastroenterol Hepatol. 2011;9:490-6.

Avances Técnicos

• Ajuste automatizado de luz (uniforme)• Mejor visualización periférica• Cromoendoscopia virtual• Indicador de sospecha de sangre (detección

áreas rojas)• Modulación en frecuencia de tomas• Imagen en tiempo real

Otras indicaciones

• Cápsula esofágica– Esofagitis, Barrett, várices

• Cápsula colon– Tamizaje pólipos

Riesgos

• Retención de cápsula – F.R: Crohn, cirugías abdominales, radioterapia, AINES– Se recomiendan imágenes en pacientes de alto riesgo– Cápsula biodegradable

• Marcapasos, resincronizadores o DAI– Malfuncionamiento dispositivo cardiaco (teórico!!!)– Deterioro calidad de imagen (raro!!)– Falla transmisión imagen (raro!!)

Contraindicaciones (eventuales)

• Demencia• Estenosis o divertículo esofágico• Gastroparesia• Obstrucción intestinal• Pacientes que rechacen o no sean

candidatos a cirugía• Embarazo

Innovaciones en estudio

• Mayor duración de la batería y ahorro de energía

• Movimiento dirigido– Dirección magnética externa– Autopropulsión y anclaje

• Insuflación• Marcaje, biopsias, tratamiento