Cross-sectional small intestinal surveillance of maintenance hemodialysis patients using video capsule endoscopy: SCHEMA study

Background and study aims: Small intestinal pathology in hemodialysis (HD) patients has been studied in only a small number of retrospective case series. One method for noninvasively surveying small intestinal disorders is video capsule endoscopy (VCE). The primary aim of this study was to investigate the prevalence of small intestinal abnormalities among asymptomatic maintenance HD outpatients using VCE. The secondary aim was to assess the clinical impact of these abnormalities.

Patients and methods: This study consisted of two phases. In phase I, a cross-sectional study, a cohort of patients who received maintenance HD three times weekly at an outpatient hemodialysis clinic were studied using VCE. Phase II was a prospective cohort study with follow up for 1 year after VCE.

Results: Fifty-six patients were enrolled in this study, and two were excluded from analysis due to capsule retention in the stomach. The prevalence of small bowel abnormalities in HD patients was 64.8 % (35/54) (95 % confidential interval 52.1 % – 77.6 %). Of 54 patients, 21 (38.9 %) had mucosal lesions, 10 (18.5 %) had vascular lesions, and 4 (7.4 %) had both lesion types. During the 1-year follow-up period, events occurred in four patients. A small bowel-associated event was observed in one patient, who underwent laparoscopy-assisted small intestinal partial resection 3 months after diagnosis by VCE. All patients in whom events were seen had small bowel abnormalities; no events were observed in the VCE-negative group.

Conclusions: Although asymptomatic maintenance HD patients had a high prevalence of small bowel abnormalities (64.8 %), they did not have a high incidence of small bowel-associated events during the 1-year follow-up.

• References

• 1 Hallan SI, Coresh J, Astor BC et al. International comparison of the relationship of chronic kidney disease prevalence and ESRD risk. J Am Soc Nephrol 2006; 17: 2275-2284
• 2 Nakai S, Hanafusa N, Masakane I et al. An Overview of Regular Dialysis Treatment in Japan (as of 31 December 2012). Ther Apher Dial 2014; 18: 535-602
• 3 Kang JY. The gastrointestinal tract in uremia. Dig Dis Sci 1993; 38: 257-268
• 4 Etemad B. Gastrointestinal complications of renal failure. Gastroenterology clinics of North America 1998; 27: 875-892
• 5 Docherty E, Koulaouzidis A, Douglas S et al. Use of small bowel capsule endoscopy in patients with chronic kidney disease: experience from a University Referral Center. Annals of Gastroenterology 2015; 28: 99-104
• 6 Arakawa D, Ohmiya N, Nakamura M et al. Outcome after enteroscopy for patients with obscure gastrointestinal bleeding bleeding: diagnostic comparison between double-balloon endoscopy and videocapsule endoscopy. Gastrointest Endosc 2009; 69: 866-874
• 7 Sotoudehmanesh R, Ali Asgari A, Ansari R et al. Endoscopic findings in end-stage renal disease. Endoscopy 2003; 35: 502-505
• 8 Sood P, Kumar G, Nanchal R et al. Chronic kidney disease and end-stage renal disease predict higher risk of mortality in patients with primary upper gastrointestinal bleeding. Am J Nephrol 2012; 35: 216-224
• 9 Saeed F, Agrawal N, Greenberg E et al. Lower gastrointestinal bleeding in chronic hemodialysis patients. Int J Nephrol 2011; 2011: 272535
• 10 Karagiannis S, Goulas S, Kosmadakis G et al. Wireless capsule endoscopy in the investigation of patients with chronic renal failure and obscure gastrointestinal bleeding (preliminary data). World J Gastroenterol 2006; 12: 5182-5185
• 11 Ohmori T, Konishi H, Nakamura S et al. Abnormalities of the small intestine detected by capsule endoscopy in hemodialysis patients. Intern Med 2012; 51: 1455-1460
• 12 Sakai E, Endo H, Taniguchi L et al. Factors predicting the presence of small bowel lesions in patients with obscure gastrointestinal bleeding. Dig Endosc 2012; 25: 412-20
• 13 Holleran G, Hall B, Hussey M et al. Small bowel angiodysplasia and novel disease associations: a cohort study. Scand J Gastroenterol 2013; 48: 433-438
• 14 Kawamura H, Sakai E, Endo H et al. Characteristics of the small bowel lesions detected by capsule endoscopy in patients with chronic kidney disease. Gastroenterol Res Pract 2013; 2013: 814214
• 15 Iddan G, Meron G, Glukhovsky A et al. Wireless capsule endoscopy. Nature 2000; 405: 417-417
• 16 Triester SL, Leighton JA, Leontiadis GI et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2005; 100: 2407-2418
• 17 Saperas E, Dot J, Videla S et al. Capsule endoscopy versus computed tomographic or standard angiography for the diagnosis of obscure gastrointestinal bleeding. Am J Gastroenterol 2007; 102: 731-737
• 18 Trifan A, Singeap AM, Cojocariu C et al. Small bowel tumors in patients undergoing capsule endoscopy: a single center experience. J Gastrointestin Liver Dis 2010; 19: 21-25
• 19 Mehdizadeh S, Chen GC, Barkodar L et al. Capsule endoscopy in patients with Crohn's disease: diagnostic yield and safety. Gastrointest Endosc 2010; 71: 121-127
• 20 von Elm E, Altman DG, Egger M et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147: 573-577
• 21 Ladas SD, Triantafyllou K, Spada C et al. European Society of Gastrointestinal Endoscopy (ESGE): recommendations (2009) on clinical use of video capsule endoscopy to investigate small-bowel, esophageal and colonic diseases. Endoscopy 2010; 42: 220-227
• 22 Korman LY, Delvaux M, Gay G et al. Capsule endoscopy structured terminology (CEST): proposal of a standardized and structured terminology for reporting capsule endoscopy procedures. Endoscopy 2005; 37: 951-959
• 23 Holden RM, Harman GJ, Wang M et al. Major bleeding in hemodialysis patients. Clin J Am Soc Nephrol 2008; 3: 105-110
• 24 Luo JC, Leu HB, Hou MC et al. Nonpeptic ulcer, nonvariceal gastrointestinal bleeding in hemodialysis patients. Am J Med 2013; 126: 264.e225-264.e232
• 25 Luo JC, Leu HB, Huang KW et al. Incidence of bleeding from gastroduodenal ulcers in patients with end-stage renal disease receiving hemodialysis. CMAJ 2011; 183: E1345-1351
• 26 Zuckerman GR, Cornette GL, Clouse RE et al. Upper gastrointestinal bleeding in patients with chronic renal failure. Ann Intern Med 1985; 102: 588-592
• 27 Tsai CJ, Hwang JC. Investigation of upper gastrointestinal hemorrhage in chronic renal failure. J Clin Gastroenterol 1996; 22: 2-5
• 28 Graham DY, Opekun AR, Willingham FF et al. Visible small-intestinal mucosal injury in chronic NSAID users. Clin Gastroenterol Hepatol 2005; 3: 55-59
• 29 Wee A, Kang JY, Ho MS et al. Gastroduodenal mucosa in uraemia: endoscopic and histological correlation and prevalence of helicobacter-like organisms. Gut 1990; 31: 1093-1096
• 30 Wang X, Uzu T, Isshiki K et al. Iron status and the use of non-steroidal anti-inflammatory drugs in hemodialysis patients. Ther Apher Dial 2007; 11: 215-219
• 31 Endo H, Hosono K, Inamori M et al. Characteristics of small bowel injury in symptomatic chronic low-dose aspirin users: the experience of two medical centers in capsule endoscopy. J Gastroenterol 2009; 44: 544-549
• 32 Endo H, Sakai E, Taniguchi L et al. Risk factors for small-bowel mucosal breaks in chronic low-dose aspirin users: data from a prospective multicenter capsule endoscopy registry. Gastrointest Endosc 2014; 80: 826-34
• 33 Watanabe T, Sugimori S, Kameda N et al. Small bowel injury by low-dose enteric-coated aspirin and treatment with misoprostol: a pilot study. Clin Gastroenterol Hepatol 2008; 6: 1279-1282
• 34 Sarosiek I, Selover KH, Katz LA et al. The assessment of regional gut transit times in healthy controls and patients with gastroparesis using wireless motility technology. Aliment Pharmacol Ther 2010; 31: 313-322
• 35 Arora Z, Parungao JM, Lopez R et al. Clinical utility of wireless motility capsule in patients with suspected multiregional gastrointestinal dysmotility. Dig Dis Sci 2015; 60: 1350-1357
• 36 Francos GC, Besarab A, Joseph RE. Disorders of oesophageal motility in chronic haemodialysis patients. Lancet 1984; 28: 219
• 37 Siamopoulos KC, Tsianos EV, Dardamanis M et al. Esophageal dysfunction in chronic hemodialysis patients. Nephron 1990; 55: 389-393
• 38 Dogan I, Unal S, Sindel S et al. Esophageal motor dysfunction in chronic renal failure. Nephron 1996; 72: 346-347