Capsule Status 2004: What is the Outcome in Bleeding? Are There Really Additional Indications?

Hardly any of the medical innovations seen in recent decades has given rise to so much interest and enthusiasm as the introduction of capsule endoscopy (CE). The method fulfilled every endoscopist’s dream of being able to examine endoscopically not only the stomach and colon, but the whole gastrointestinal tract. All previous attempts to achieve total enteroscopy using conventional endoscopes had to a greater or lesser extent failed.

However, assessing the real significance of capsule endoscopy in small-bowel diseases requires prospective studies comparing the capsule with push enteroscopy (PE), intraoperative endoscopy, and other imaging procedures in relation to defined issues.

Six valid full papers have now been published on the detection of mid-gastrointestinal bleeding with CE, showing a trend toward similar results [1] [2] [3] [4] [5] [6]. In comparison with push enteroscopy, CE produces approximately twice as many positive findings. Conventional procedures such as small-bowel radiography, angiography, and nuclear medicine techniques (e. g., blood pool scintigraphy) have been relegated to the status of reserve procedures [1]. Whether push enteroscopy should be used before CE is an open question, at least in relation to obscure occult mid-gastrointestinal bleeding. In obscure overt bleeding from the mid-gastrointestinal tract, the first choice is undoubtedly PE, since coagula and blood can be rinsed away with this method and therapeutic hemostatic procedures can also be carried out.

However, what is the use of better detection of bleeding sources in the mid-gastrointestinal tract if it does not have a positive influence on the outcome for patients? While this question was never asked in connection with ”older” procedures in the fields of radiography, nuclear medicine, and endoscopy, it can now justifiably be asked not only of CE but also of the ”older” procedures as well - not only for scientific reasons, but in particular for economic reasons. However, scientific research is faced with substantial methodological problems in answering this question, since it is not only ”acute events” that need to be investigated; complex and meticulous follow-up procedures need to be recorded over long periods. In their paper in this issue of Endoscopy, Delvaux et al. can therefore take the credit for what is in our view the best-validated paper on the topic to date [7]. In 44 patients with occult or overt bleeding, CE diagnosed mid-gastrointestinal bleeding in nearly 40 % of cases. After appropriate endoscopic, surgical, or medical therapy, recurrent bleeding was only observed in one patient after a follow-up period of 1 year. Conversely, a different plausible explanation for the anemia was found in all of the patients with negative CE findings, so that the negative predictive value was as high as 100 %. Although the study by this French group will require further confirmation from similarly good outcome studies, as it was a single-center investigation with a small number of cases, this important study further bolsters the significance of CE in a structured work-up for obscure bleeding.

While the reservations on the part of health insurance companies at the time of the introduction of CE were justified and understandable [8], it is now high time for them to accept the costs of this useful and effective method of clarifying chronic obscure gastrointestinal bleeding, as it avoids the need for unnecessary additional investigations and can have a decisive influence on the outcome.

With regard to additional indications for CE, the ESGE guidelines are generously formulated [8]: ”Currently accepted indications are the investigation of Crohn’s disease, evaluation of side effects of NSAIDs and hereditary polyposis syndromes such as familial adenomatous polyposis (FAP).” From our point of view, the data published to date regarding CE in Crohn’s disease are too weak - both methodologically and due to the small numbers of patients studied - to establish a standard indication for CE outside of clinical studies [9] [10] [11]. The available data are also very weak with regard to the polyposis syndromes. The two studies on this topic also published in this issue of Endoscopy are therefore welcome; these studies well illustrate the value of CE for Peutz-Jeghers polyposis in particular, and show consistent results [12] [13]. In view of the clinical relevance of intestinal Peutz-Jeghers polyposis (ileus due to polyp obstruction, with a risk of malignant degeneration) [12], on the one hand, and the high prevalence of polyps in the small bowel at almost 100 %, on the other, CE appears to be a valuable and mandatory indication not only for initial staging, but also for regular follow-up in patients with Peutz-Jeghers syndrome (PJS). In contrast to PJS, the prevalence of adenomatous polyps in the jejunum and ileum in FAP patients appears to be much lower. In a study conducted in Germany, only 50 % of FAP patients (eight of 16) were found to have adenomas at CE, most of which were located in the duodenum. One practical implication of this might be that CE is only justified in patients with FAP if standard endoscopy shows adenomas in the stomach and duodenum, but not if the upper gastrointestinal tract is free of them. In addition, the role of PE has yet to be evaluated in comparison with CE in FAP patients.

With regard to the challenge of magnetic resonance imaging (MRI) of the small bowel, the situation appears to be similar to that with virtual colonoscopy - it is possible to visualize large polyps using small-bowel MRI. The smaller the polyps, the poorer the detection rate with MRI. Since MRI imaging of the small bowel, with its length of 4 - 6 m, is much more sophisticated and difficult than imaging of the large bowel, neither MRI nor conventional or CT radiographic methods are capable of competing successfully with CE, at least at present. CE has the highest diagnostic yield and is much more comfortable for patients than MRI or radiographic techniques.

Four years after the introduction of capsule endoscopy into clinical gastroenterology, the method has become an established part of the diagnostic armamentarium. It is superior to all other diagnostic methods in cases of obscure bleeding. The study by Delvaux et al. shows that as part of a structured work-up, CE is capable of substantially influencing the outcome. In hereditary hemorrhagic telangiectasia (HHT), which an Italian group report on in this issue of Endoscopy [14], CE should be among the primary diagnostic procedures. In polyposis syndromes of the PJS type, there is already a good and valuable indication for capsule endoscopy. CE is capable of becoming the method of choice for early detection of Crohn’s disease. However, it will only be possible to confirm this with a methodologically flawless multicenter study including adequate numbers of patients. The same also applies to the problem of celiac disease. The imminent universal introduction of push-and-pull enteroscopy (PPE) using the double-balloon technique [16] will initially support and strengthen the indication for capsule endoscopy, since after diagnostic clarification with capsule endoscopy, PPE allows targeted biopsies and interventional treatment throughout the entire small bowel without the need for laparotomy. A new challenge for the future will be the use of CE to screen for Barrett’s esophagus (Pillcam).

References

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