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Is the capsule a guiding star ?

Is the capsule a guiding star ?. Dr. Niv Eva Department of Gastroenterology Tel-Aviv Sourasky Medical Center. First Case. 44 y.o. woman 13 years ago Abdominal pain, diarrhea Normal colonoscopy+ileoscopy (including biopsies) Small bowel passage– thickening of middle part of small bowel

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Is the capsule a guiding star ?

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  1. Is the capsule a guiding star ? Dr. Niv Eva Department of Gastroenterology Tel-Aviv Sourasky Medical Center

  2. First Case

  3. 44 y.o. woman 13 years ago Abdominal pain, diarrhea Normal colonoscopy+ileoscopy (including biopsies) Small bowel passage– thickening of middle part of small bowel Diagnosis:Crohn’s disease of mid- small intestine Treatment: Azathioprine ( 3-4 y)– good response, but leukopenia  stopped 5ASA, prednisone– good response Recently asymptomatic  all medications stopped

  4. 10 months ago Abdominal pain, diarrhea, weight loss Hypokalemia, hypomagnesemia, anemia, hypoalbuminemia (3.0 g/dL) Two weeks later– hospitalization small intestinal intussusception CT: Thickening of all small intestine (especially – mid), mesenteric lymphadenopathy

  5. Conservative treatment Resolution of intussusception  discharge Follow up visit in the Dept of Gastroenterology Looks ill, still abdominal pain severe diarrhea (~2000 cc of stool/day), weight loss (6-7 kg), BMI 19, hypoalbuminemia (2.7 g/dL)

  6. Ileo-colonoscopy– normal • Normal biopsies from colon and terminal ileum • Video capsule endoscopy (another medical center) Normal Small Intestinal Mucosa. Revision of the film…

  7. Normal small intestinal mucosa

  8. What is the diagnosis of the patient ?

  9. Scalloped folds, lack of villi, mosaic pattern Diagnosis— Celiac disease DD: Lymphoma, Mastocytosis, Eosinophilic gastroenteritis, Hypogammaglobulinemia, Giardiasis, Tropical sprue

  10. Enteroscopy

  11. Anti TTG positive (high titer) The diagnosis of celiac disease was established The mystery was resolved: • No evidence of Crohn’s disease • The recent deterioration was explained by wheat-based diet • Celiac disease is a known cause of intussusception Gluten-free diet was started with quick improvement The possibility of T cell lymphoma was excluded

  12. Folow up in 10 months • The patient adheres to gluten-free diet • The patient is asymptomatic • Normal nutritional state, normal blood tests

  13. Summary of First Case • In this case capsule endoscopy was a blessing by finding the right diagnosis when other imaging tests were misleading.

  14. Endoscopy 2005ICCE Consensus for Celiac Disease ,,All video capsule endoscopists need to be familiar with the changes characteristic of celiac disease.’’ Indications for capsule endoscopy in celiac disease: • Persistent or alarm symptoms in patients with established celiac disease • Initial diagnosis in patient with positive celiac serology who is unwilling or unable to undergo EGD

  15. Second Case

  16. 74 y.o. male • IHD, s/p CABG X2, recently asymptomatic • PAF • Medications: amiodarone, clopidogrel • 2 y.a.– Laparoscopic inguinal hernia repair • 1 y.a.—Small bowel obstruction Laporoscopic adhesiolysis (a few adhesions in unrelated area)

  17. During the following 6 months– Recurrent episodes of small intestinal obstruction Conservative treatment CT abdomen– Thickening and mild dilation of mid-small intestinal loop

  18. On the basis of clinical picture surgery was planned • But the surgeon asked to perform capsule endoscopy first

  19. Small submucosal lesion Discrete areas of inflammation and erosions

  20. Stricturingulcers

  21. What is the differential diagnosis of the patient ? What should be the strategy ?

  22. DD • Crohn’s disease • NSAIDs or other medications • Lymphoma • TB • Ischemia due to atherosclerosis or intermittent intussusception (submucosal tumors, adhesions) • Ulcerative jejunoileitis

  23. Work-up • No medications except for amiodarone and clopidogrel • Lab tests– CBC, SMA, CRP normal • Colonoscopy (including biopsies)– normal • Gastroscopy– normal • Enteroscopy (including biopsies)– normal • ASCA, ANCA negative

  24. The dilemma: To operate or to give empirical treatment Decision– prednisone trial prednisone 40 mgx1 for 2 weeks—failure Tapering down

  25. Operation No evidence of Crohn’s disease (no transmural inflammation, no fat wrapping) No evidence of lymphoma (no lymphadenopathy) Normal small bowel (outside view) Multiple adhesions with segmental pressure on small bowel Biopsy from adhesions: Fibrotic tissue. No granulomas Suggestion: adhesions and recurrent episodes of small bowel obstruction caused secondary ischemic changes in the bowel

  26. Am J Surg 2005; 190: 886-90 The utility of capsule endoscopy and its role for diagnosing pathology in the GI tract Carlo JT et al

  27. Follow up in 6 months • The patient is asymptomatic • No additional events of small bowel obstruction

  28. Summary of Second Case • In this case capsule endoscopy delayed the definitive treatment (operation) by several months

  29. Thank you for your attention

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