Small-bowel endoscopy

Improved visibility of lesions of the small bowel intestine via capsule endoscopy with computed virtual chromoendoscopy (Imagawa et al., Gastrointest Endosc 2011 [1])

In recent years, several studies have reported on an improvement in the visualization and classification of lesions in the upper and lower gastrointestinal tract using computed virtual chromoendoscopy (CVC), such as narrow-band imaging (NBI), flexible spectral imaging color inhancement (FICE) or i-Scan. CVC enhances the contrast of the mucosal surface without the use of dyes. The FICE system is based on narrowing of the bandwidth of the conventional endoscopic image arithmetically by a spectral estimation technology and enhances the vascular network as well as the pit pattern, facilitating the assessment of gastrointestinal mucosal lesions [2]. Neumann et al. described for the first time the use of double-balloon enteroscopy (DBE) and the FICE system for classification of small-bowel lesions in a case series [3]. FICE was found to be a helpful method for the evaluation of adenomatous small-bowel polyps and angiodysplasias [3].

The retrospective trial by Imagawa et al. investigated the value of the FICE system for detection of small-bowel lesions using video capsule endoscopy (PillCam SB1; Given Imaging Ltd., Yokneam, Israel) for evaluation of the small bowel [1]. For this new technique the FICE software was installed in the video capsule workstation (CE-FICE). The FICE images were compared with the conventional capsule images by five physicians, using 145 lesions from 122 patients who underwent capsule endoscopy for suspected small-bowel disease. The main indication was suspected mid-gastrointestinal bleeding. The analysis of the images was carried out with Rapid Reader 6 software. Three FICE settings were evaluated. The authors found an improved image quality for angiodysplasias (87 %), erosions and ulcerations (53 %), and tumors (25 %) for FICE setting 1 and similar results for FICE setting 2. They therefore concluded that the CE-FICE system improves the visibility of these small-bowel lesions.

These findings confirm the results of a pilot study of 10 consecutive patients, which was conducted by our working group and published in 2010 [4]. Pohl et al. demonstrated that FICE technology could facilitate the detection of lesions that had a tendency to bleed. However, the number of non-relevant lesions detected using this technology also increased. In contrast to these latter two studies, Gupta et al. found that it was mainly the detection of non-pathological lesions that was improved, and that there was only a slight advantage for detection of vascular lesions [5]. One reason might be the use of different PillCam devices. The PillCam SB1 device was used in the study by Imagawa et al., whereas Gupta et al. used the PillCam SB2 device, which is equipped with better technology and provides higher white light image quality. As has already been shown for Barrett’s esophagus and colon polyps, CVC cannot increase the detection rate of lesions, but does help to classify them. This might be different in the small bowel due to different indications. It seems that the best results from CE-FICE can be achieved in bleeding lesions, which are the main indication for evaluation of the small bowel. Multicenter trials are necessary to clarify the real value of the CE-FICE and to determine the best indications for this modality.

• References

• 1 Imagawa H, Oka S, Tanaka S et al. Improved visibility of lesions of the small bowel intestine via capsule endoscopy with computed virtual chromoendoscopy. Gastrointest Endosc 2011; 73: 299-306
• 2 Pohl J, May A, Rabenstein T et al. Computed virtual chromoendoscopy: a new tool for enhancing tissue surface structures. Endoscopy 2007; 39: 80-83
• 3 Neumann H, Fry LC, Bellutti M et al. Double-balloon enteroscopy-assisted virtual chromoendoscopy for small-bowel disorders: a case series. Endoscopy 2009; 41: 468-471
• 4 Pohl J, Aschmoneit I, Schuhmann S et al. Computed image modification for enhancement of small-bowel surface structures at video capsule endoscopy. Endoscopy 2010; 42: 490-492
• 5 Gupta T, Ibrahim M, Deviere J et al. Evaluation of Fujinon intelligent chromo endoscopy-assisted capsule endoscopy in patients with obscure gastroenterology bleeding. World J Gastroenterol 2011; 17: 4590-4595
• 6 Pioche M, Gaudin JL, Filoche B et al. Prospective randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding. Gastrointest Endosc 2011; 73: 1181-1188
• 7 Bang S, Park JY, Jeong S et al. First clinical trial of the “MiRo” capsule endoscope by using a novel transmission technology: electric-field propagation. Gastrointest Endosc 2009; 69: 253-259
• 8 Kim HM, Kim YJ, Kim HJ et al. A pilot study of sequential capsule endoscopy using MiroCam and PillCam SB devices with different transmission technologies. Gut Liver 2010; 4: 192-200
• 9 Xin L, Liao Z, Jiang YP et al. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc 2011; 74: 563-570
• 10 Yamamoto H, Sekine Y, Sato Y et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001; 53: 216-220
• 11 May A, Nachbar L, Wardak A et al. Double-balloon enteroscopy: preliminary experience in patients with obscure gastrointestinal bleeding or chronic abdominal pain. Endoscopy 2003; 35: 985-991
• 12 Zhong J, Ma T, Zhang C et al. A retrospective study of the application on double-balloon enteroscopy in 378 patients with suspected small-bowel diseases. Endoscopy 2007; 39: 208-215
• 13 Möschler O, May A, Müller MK et al. Complications in and performance of double-balloon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy 2011; 43: 484-489
• 14 Takano N, Yamdada A, Watabe H et al. Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial. Gastrointest Endosc 2011; 73: 734-739
• 15 May A, Färber M, Aschmoneit I et al. Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol 2010; 105: 575-581
• 16 Domagk D, Mensink P, Aktas H et al. Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trail. Endoscopy 2011; 43: 472-476
• 17 Yamamoto H, Kita H, Sunada K et al. Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol 2004; 2: 1010-1016
• 18 May A, Friesing-Sosnik T, Manner H et al. Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding. Endoscopy 2011; 43: 759-765
• 19 Madisch A, Schmolders J, Brückner S et al. Less favorable clinical outcome after diagnostic and interventional double balloon enteroscopy in patients with suspected small-bowel bleeding?. Endoscopy 2008; 40: 731-734
• 20 Gerson LB, Batenic MA, Newsom SL et al. Long-term outcomes after double-balloon enteroscopy for obscure gastrointestinal bleeding. Clin Gastroenterol Hepatol 2009; 7: 664-669