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Achieving safe endoscopic skills is quintessential for a pediatric gastroenterologist to effectively manage various gastrointestinal conditions. This has become more important as the latest international guidelines stress on the importance of complete bowel workup for surveillance and reassessment of pediatric inflammatory bowel disease. A pediatric endoscopist needs to have more refined and age-appropriate diagnostic and therapeutic endoscopic skills as compared to their adult counterpart. This chapter details the essential principles required to achieve safe and effective endoscopic skills including patient preparation, update on use of prophylactic antibiotic, equipment required, and step-by-step approach to achieve full ileocolonoscopy and enteroscopy, including double balloon enteroscopy. A section is dedicated to pediatric inflammatory bowel disease including endoscopic findings, classification, treatment targets, and new scoring system for assessing disease severity. New advances in endo-diagnostic gastrointestinal procedures including wireless capsule endoscopy, colon capsule endoscopy, high magnification chromoscopic colonoscopy, confocal LASER endoscopy, and endosonography are also discussed.

Background Suspected small bowel bleeding (SSBB) is the main indication for videocapsule endoscopy (VCE) and double balloon enteroscopy (DBE). We assessed the impact of both modalities in a large cohort of SSBB patients in a European tertiary center. Methods We retrospectively evaluated consecutive patients with SSBB undergoing VCE and/or DBE from March 2001 to July 2020. Demographic/clinical parameters, anticoagulant therapies, technical characteristics and adverse events were collected, as well as diagnostic yield (DY), VCE–DBE concordance, hemoglobin (Hb) values before and after DBE, and complications. Results 807 VCEs and 407 DBEs were performed in 751 patients. The DY was significantly higher in DBE compared with VCE (68.8% vs 57.7%), with the highest (75%) yield for overt active SB bleeding. The agreement between VCE and DBE was generally suboptimal (k = 0.059). This improved in cases where both procedures were done within 1–5 days of the other (k = 0.323). Post-procedural Hb values were significantly higher. In patients treated with direct oral anticoagulants (DOACs), there were no differences in DY, complications or Hb values compared with non-DOAC patients. Conclusion VCE and DBE play a pivotal role in the diagnostic and therapeutic approach to SSBB, having a high clinical impact even in patients treated with DOACs.

Celiac disease is a systemic autoimmune disorder leading to manifestations of malabsorption syndrome. A 47-year-old Japanese man developed severe diarrhea after surgery for gastric cancer. The diarrhea persisted for seven months, leading to a state of malabsorption. Celiac disease was suspected based on small bowel capsule endoscopy findings. The duodenal findings observed during gastric cancer surgery were reassessed, and Marsh-Oberhuber classification type 3c celiac disease was diagnosed. The anti-tissue glutaminase antibody test results were positive. The patient was started on a gluten-free diet, following which the diarrhea resolved, and the nutritional status improved. Adjuvant therapy after gastric cancer surgery was initiated.

Background & aims : Small intestinal involvement in familial adenomatous polyposis (FAP) remains unclarified. We performed capsule endoscopy (CE) and balloon-assisted (BA) endoscopy to analyze small intestinal polyps and their genotype-phenotype correlations in a large cohort of FAP patients. Methods : In this retrospective study, we performed CE in all 149 FAP patients and BA endoscopy in 74 patients with larger polyps. The prevalence of small intestinal adenoma with high-grade dysplasia and cancer was investigated. Correlation between APC variant and polyp phenotype was analyzed. Results : Median patient age was 44 years and 69% were male. Pathogenic germline APC variants were found in 117/136 (86.1%). Overall prevalence and median number of small intestinal polyps were 85.2% (127/149) and 17 (IQR 6-36), respectively. A total of 5318 polyps were detected by CE and all 433 polyps histologically examined were confirmed as adenoma. The number of polyps significantly decreased from the proximal-to-distal tracts. Adenoma with high-grade dysplasia was detected in 26.2% (39/149), and its incidence among the polyps was approximately 1.4% (74/5318). Of these, 14 were intramucosal carcinomas with a prevalence of 5.4% (8/149). The germline APC variant in codon 1251-1580 was significantly correlated with a high number of small intestinal polyps. Multivariate analysis revealed APC variant in codon 1251-1580 and a high number of small intestinal polyps as independent risk factors for adenoma with high-grade dysplasia. Spigelman stage was significantly associated with number of jejunal/ileal polyps and their high-grade dysplasia. Conclusions : Among FAP patients, small intestinal adenoma with high-grade dysplasia was detected in 26.2% and cancer in 5.4%. FAP patients, particularly those with APC variant in codon 1251-1580 and/or high Spigelman stage may require surveillance for small intestinal polyps.

Gastrointestinal bleeding is the most frequent major complication of antiplatelet therapy. In patients at low bleeding risk, however, clinically overt gastrointestinal bleeding is relatively uncommon.The authors sought to assess the effects of different antiplatelet regimens on gastrointestinal mucosal injury by means of a novel magnetically controlled capsule endoscopy system in patients at low bleeding risk.Patients (n = 505) undergoing percutaneous coronary intervention in whom capsule endoscopy demonstrated no ulcerations or bleeding (although erosions were permitted) after 6 months of dual antiplatelet therapy (DAPT) were randomly assigned to aspirin plus placebo (n = 168), clopidogrel plus placebo (n = 169), or aspirin plus clopidogrel (n = 168) for an additional 6 months. The primary endpoint was the incidence of gastrointestinal mucosal injury (erosions, ulceration, or bleeding) at 6-month or 12-month capsule endoscopy.Gastrointestinal mucosal injury through 12 months was less with single antiplatelet therapy (SAPT) than with DAPT (94.3% vs 99.2%; P = 0.02). Aspirin and clopidogrel monotherapy had similar effects. Among 68 patients without any gastrointestinal injury at randomization (including no erosions), SAPT compared with DAPT caused less gastrointestinal injury (68.1% vs 95.2%; P = 0.006), including fewer new ulcers (8.5% vs 38.1%; P = 0.009). Clinical gastrointestinal bleeding from 6 to 12 months was less with SAPT than with DAPT (0.6% vs 5.4%; P = 0.001).Despite being at low risk of bleeding, nearly all patients receiving antiplatelet therapy developed gastrointestinal injury, although overt bleeding was infrequent. DAPT for 6 months followed by SAPT with aspirin or clopidogrel from 6 to 12 months resulted in less gastrointestinal mucosal injury and clinical bleeding compared with DAPT through 12 months. (OPT-PEACE [Optimal Antiplatelet Therapy for Prevention of Gastrointestinal Injury Evaluated by Ankon Magnetically Controlled Capsule Endoscopy]; NCT03198741).

Background Capsule endoscopy (SBCE) has developed a relevant role in patients with established Crohn's Disease (CD). However, evaluation of the impact in clinical management has been scarce. Aims To evaluate therapeutic impact of SBCE in an 11-year real-life cohort of known CD patients. Methods Retrospective single center study including all patients with established CD submitted to SBCE procedure from 01/01/2008 to 31/12/2019. Patency capsule was used in selected patients. Small bowel mucosal inflammation was quantified using Lewis score. Therapeutic impact was defined as a change in CD-related treatment recommended based on SBCE results. Patients were assigned to four groups regarding SBCE indication: staging, flare, post-op and remission. Results From the 432 SBCE performed 87.5% were conclusive. Active disease was present in 63.7 of patients; 41.6% mild inflammation and 21.9% moderate-to-severe activity. A change of management was guided by SBCE in 51.3% of procedures: 199 (46.1%) escalation and 23 (5.3%) de-escalation, with significant changes in all groups. Escalation increased with disease activity: 57.8% in mild and 89.5% in moderate-to-severe disease. De-escalation was conducted in 13.9% procedures with mucosal healing and 1.1% with mild disease. Conclusion SBCE is a useful tool for guiding therapeutic management in CD patients both for treatment escalation and de-escalation.

Background Colon Capsule Endoscopy (CCE) has proven efficacy in a variety of gastrointestinal diseases. Few studies have assessed patient-reported outcomes and preference between colonoscopy and CCE. Methods Patients from our centre who had both a CCE and colonoscopy within a 12-month period were identified. We performed over-the-phone interviews focused on satisfaction, comfort, and overall preference with a 10-point Likert scale. Electronic records were reviewed; reported Modified-Gloucester-Comfort-Scale (GCS) score, sedation, bowel preparation and endoscopist grade were documented. Data was compared between procedures. A Fishers exact test was used to compare proportions and a Student t-test was used to compare means, a p Results In all, 40 patients were identified, 57.5% (23/40) were female and the mean age was 48 years (24–78). All patients were referred for investigation of lower gastrointestinal symptoms as part of an ongoing study [Endosc Int Open. 2021;09(06):E965–70]. There was a significance difference in mean comfort (9.2 vs 6.7, p p = 0.2, 95% CI − 1.48 to 0.33) between CCE and colonoscopy. Main cause of dissatisfaction with CCE was bowel preparation and for colonoscopy was discomfort. Age and gender were not found to be variables. The correlation between GCS and patient reported values was weak (R = − 0.28). Overall, 77.5% (31/40) of patients would prefer a CCE if they required further bowel investigation. Of these, 77.4% (24/31) preferred a CCE despite the potential need for follow-up colonoscopy. Conclusions CCE has a high satisfaction rating (8.3 vs 7.7) and has a higher patient reported comfort rating (9.2 vs 6.7) than colonoscopy. Studies have confirmed CCE and colonoscopy have equivalent diagnostic yields. The majority of patients in our cohort prefer CCE to colonoscopy. CCE should be considered as an alternative to colonoscopy in selected individuals.

Background Small Bowel Capsule Endoscopy is the first-choice technique for investigating the majority of small bowel diseases. Its most common complications are related to incomplete examinations and capsule retention. There is no consensus on how patients with previous gastrointestinal surgery should receive the capsule. Objective The primary endpoint was to compare the rate of complete small-bowel examinations (completion rate) between oral ingestion and endoscopic delivery of the capsule. The secondary endpoint was to compare diagnostic yield and adverse events in the two groups. Methods A retrospective observational study was conducted in nine hospitals in Spain. Demographic data, previous surgery, indication for capsule endoscopy, intestinal transit time, diagnosis, completion rate (percentage of capsules reaching the caecum), diagnostic yield (percentage of results compatible with indication for the exam) and adverse events were collected. Results From January 2009 to May 2019 fifty-seven patients were included (39 male, mean age 66 ± 15 years). The most common indications for the exam were “overt” (50.9%) and “occult” (35.1%) small bowel bleeding. Previous Billroth II gastrectomy and Roux-en-Y gastric bypass were present in 52.6% and 17.5% of patients respectively. The capsule was swallowed in 34 patients and placed endoscopically in 23 patients. No significant differences were observed between the oral ingestion and endoscopic delivery groups in terms of completion rate (82.4% vs. 78.3%; p = 0.742), diagnostic yield (41.2% vs. 52.2%; p = 0.432) or small bowel transit time (301 vs. 377 min, p = 0.118). No capsule retention occurred. Only one severe adverse event (anastomotic perforation) was observed in the endoscopic delivery group. Conclusions In our case series, there were no significant differences between oral ingestion and endoscopic delivery in terms of completion rate, diagnostic yield or safety. Being less invasive, oral ingestion of the capsule should be the first-choice method in patients with previous gastrointestinal surgery.

Resumen Introduccion La capsula endoscopica de intestino delgado (CEID) es una tecnica diagnostica poco invasiva cuyo empleo en la enfermedad inflamatoria intestinal (EII) se ha extendido. Se ha desarrollado recientemente una capsula panenterica, PillCamCrohn's (PCC). Carecemos de informacion sobre la disponibilidad y el uso de la CEID y la PCC en nuestro medio. Metodos Realizamos una encuesta electronica y anonima entre los miembros del Grupo Espanol de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa y la Asociacion Espanola de Gastroenterologia consistente en 37 preguntas de respuesta multiple. Resultados Participaron 150 miembros, la mayoria con dedicacion especial a la EII (69,3%). El 72,8% trabajaban en centros con unidad de EII. El 79% tenian la CEID disponible en su hospital, y el 14% la derivaban a otro centro. El 22% tenian disponible la PCC, y el 9% la derivaban a otro centro. El 79,3% de encuestados con CEID disponible la utilizaban en un pequeno porcentaje de pacientes con EII y el 15,6% en la mayoria. Los escenarios mas frecuentes fueron la sospecha de enfermedad de Crohn (76,3%), la valoracion de actividad inflamatoria (54,7%) y la evaluacion de la extension de la enfermedad (54,7%). Mas de la mitad (59,7%) utilizaban preferentemente la capsula Patency® para valoracion de la permeabilidad intestinal. Casi todos los encuestados (99,3%) consideraban que se deberian implementar recursos formativos en esta tecnica. Conclusiones La CEID cuenta con una amplia disponibilidad en los hospitales espanoles para el manejo de la EII, si bien su uso es todavia limitado. Existe una oportunidad para aumentar la formacion en esta tecnica, y, con ella, su empleo.

Background Gastrointestinal endoscopy is frequently recommended for chronic diarrhea assessment in Western countries, but its benefit in the Southeast Asia region is not well established. Methods Medical records of consecutive patients undergoing esophagogastroduodenoscopy (EGD), colonoscopy, and small bowel endoscopy for chronic diarrhea from 2008 to 2018 were reviewed. Small bowel endoscopy included push enteroscopy, balloon-assisted enteroscopy (BAE), and video capsule endoscopy (VCE). The diagnostic yield of each endoscopic modality and predictors for positive small bowel endoscopy were analyzed. Results A total of 550 patients were included. The mean age was 54 years, and 266 (46.3%) patients were male. The mean hemoglobin and albumin levels were 11.6 g/dL and 3.6 g/dL, respectively. EGD and colonoscopy were performed in 302 and 547 patients, respectively, and the diagnostic yield was 24/302 (7.9%) for EGD and 219/547 (40.0%) for colonoscopy. EGD did not reveal positive findings in any patients with normal colonoscopy. Fifty-one patients with normal EGD and colonoscopy underwent small bowel endoscopy. Push enteroscopy, BAE, and VCE were performed in 28, 21, and 19 patients with a diagnostic yield of 5/28 (17.9%), 14/21 (66.7%), and 8/19 (42.1%), respectively. Significant weight loss, edema, and hypoalbuminemia were independent predictors for the positive yield of small bowel endoscopy. Conclusion Colonoscopy was an essential diagnostic tool in identifying the cause of chronic diarrhea in Thai patients, whereas EGD provided some benefits. Small bowel endoscopy should be performed when colonoscopy and EGD were negative, particularly in patients with significant weight loss, edema, and hypoalbuminemia.

Background and study aims Colon capsule endoscopy (CCE) is an alternative to conventional colonoscopy (CC) in specific clinical settings. High completion rates (CRs) and adequate cleanliness rates (ACRs) are fundamental quality parameters if CCE is to be widely implemented as a CC equivalent diagnostic modality. We conducted a systematic review and meta-analysis to investigate the efficacy of different bowel preparations regimens on CR and ACR in CCE. Patients and methods We performed a systematic literature search in PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library. Data were independently extracted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The primary outcome measures (CR, ACR) were retrieved from the individual studies and pooled event rates were calculated. Results Thirty-four observational (OBS) studies (n = 3,789) and 12 randomized clinical trials (RCTs) (n = 1,214) comprising a total 5,003 patients were included. The overall CR was 0.798 (95 % CI, 0.764–0.828); the highest CRs were observed with sodium phosphate (NaP) + gastrografin booster (n = 2, CR = 0.931, 95 % CI, 0.820–0.976). The overall ACR was 0.768 (95 % CI, 0.735–0.797); the highest ACRs were observed with polyethylene glycol (PEG) + magnesium citrate (n = 4, ER = 0.953, 95 % CI, 0.896–0.979). Conclusions In the largest meta-analysis on CCE bowel preparation regimens, we found that both CRs and ACRs are suboptimal compared to the minimum recommended standards for CC. PEG laxative and NaP booster were the most commonly used but were not associated with higher CRs or ACRs. Well-designed studies on CCE should be performed to find the optimal preparation regimen.

Summary Background The use of magnetically controlled capsules for gastroscopy is in the early stages of clinical adoption. We aimed to evaluate the safety and efficacy of a fully automated magnetically controlled capsule endoscopy (FAMCE) system in clinical practice for gastroscopy and small bowel examination. Methods We did a prospective, comparative study to evaluate the safety and efficacy of FAMCE. Patients from two hospitals in Chongqing, China were consecutively enrolled. Eligible participants were aged 18–80 years with suspected gastric pathology and no previous surgery. Participants underwent FAMCE for screening of gastric lesions, then conventional transoral gastroscopy 2 h later, and stomach examination results were compared. The primary outcome was the rate of complete detection of gastric anatomy landmarks (cardia, fundus, body, angulus, antrum, and pylorus) by FAMCE. Secondary outcomes were the time required for gastric completion by FAMCE, the rate of detection of gastric lesions by FAMCE compared with conventional transoral gastroscopy, and the rate of complete small bowel examination. Adverse events were also evaluated. The study was registered in the Chinese Clinical Trial Registry, ChiCTR2000040507. Findings Between May 12 and Aug 17, 2020, 114 patients (mean age 44·0 years [IQR 34·0–55·0]; 63 [55%] female) were enrolled. The rate of complete detection of gastric anatomical structures by FAMCE was 100% (95% CI 99·3–100·0). The concordance between FAMCE and conventional transoral gastroscopy was 99·61% (99·45–99·78). The mean completion time of a gastroscopy with FAMCE was 19·17 min (SD 1·43; median 19·00, IQR 19·00–20·00), compared with 5·21 min (2·00; 5·18, 3·68–6·45) for conventional transoral gastroscopy. In 114 enrolled patients, 214 lesions were detected by FAMCE and conventional transoral gastroscopy. Of those, 193 were detected by both modalities. FAMCE missed five pathologies (four cases of gastritis and one polyp), whereas conventional transoral gastroscopy missed 16 pathologies (12 cases of gastritis, one polyp, one fundal xanthoma, and two antral erosions). FAMCE was able to provide a complete small bowel examination for all 114 patients and detected intestinal lesions in 50 (44%) patients. During the study, two (2%) patients experienced adverse events. No serious adverse events were recorded, and there was no evidence of capsule retention. Interpretation The performance of FAMCE is similar to conventional transoral gastroscopy in completion of gastric examination and lesion detection. Furthermore, it can provide a complete small bowel examination. Therefore, FAMCE could be effective method for examination of the gastrointestinal tract. Funding Chinese National Key Research and Development Program.

Objective Antithrombotic drugs are being used increasingly frequently to prevent cardiovascular diseases. Few studies have evaluated small bowel mucosal injury induced by dual antiplatelet therapy (DAPT). The aim of the present study was to evaluate small bowel mucosal injury induced by DAPT compared with other antithrombotics using video capsule endoscopy (VCE). Methods The study included chronic users of antithrombotics who underwent VCE for obscure gastrointestinal bleeding between January 2007 and July 2018. We evaluated the instances of small bowel injury classified into erosions and ulcers. Results Overall, 183 patients (114 men and 69 women; mean age, 73.6 years old) were enrolled, and the study groups comprised 49 patients taking low-dose aspirin (LDA) only, 50 taking anticoagulants only, 37 being treated with DAPT, 33 on combined LDA and anticoagulants, and 14 taking P2Y12 inhibitors. Small bowel erosions and ulcers were most frequently observed in the DAPT group, with frequencies of 78.4% and 37.8%, respectively. Exacerbating factors of small bowel ulcers were DAPT [odds ratio (OR) 3.0, 95% confidence interval (CI) 1.2-7.7] and age over 80 years old (OR 2.4, 95% CI 1.1-5.4). Conclusion P2Y12 inhibitors seem to exacerbate LDA-induced small bowel injury. Preventive strategies for small bowel injury induced by LDA, especially DAPT, are urgently required.

Non-steroidal anti-inflammatory drugs (NSAIDs) can cause small bowel damage, which could present in different ways, including abdominal pain and occult gastrointestinal bleeding. NSAID use can also result in small bowel strictures, which can be challenging to diagnose and manage. Here, we describe a case of a 49-year-old female who presented with chronic anaemia and intermittent abdominal pain, with a history of NSAID use. She underwent capsule endoscopy as part of the workup for anaemia and subsequently had capsule retention due to a small bowel stricture.

Background Patients with Crohn’s disease (CD) undergo frequent endoscopic procedures, with visualization of the gastrointestinal mucosa central to treatment decision-making. Subsequently, a noninvasive alternative to optical colonoscopy (OC) would be welcomed. One such technology is capsule endoscopy, including the PillCam COLON 2 (PCC2), though research validating its use in ileocolonic CD is limited. This study aims to compare PCC2 with ileocolonoscopy (OC) in assessing mucosal CD through use of a standardized scoring system. Methods At an Australian tertiary hospital, same-day PCC2 and ileocolonoscopy results of 47 CD patients, with known nonstricturing disease, were prospectively collected and analyzed for correlation and agreement. Deidentified recordings were reported by a single expert gastroenterologist. Mucosal disease was quantified using the Simple Endoscopic Score for Crohn’s Disease (SES-CD). The SES-CD results of paired endoscopic modalities were compared in total per bowel segment and per SES-CD variable. Results Of 47 PCC2 recordings, 68% were complete, fully assessing terminal ileum to rectum, and OC was complete in 89%. Correlation (r) between total SES-CD scores was strongest in the terminal ileum (r = 0.77, P < .001), with the SES-CD variable of “ulcer detection” showing the strongest agreement. The PCC2 (vs OC) identified additional ulcers in the terminal ileum; ascending, transverse, and descending colon; and rectum; scores were 5 (1), 5 (3), 1 (1), 2 (1), and 2 (2), respectively. Conclusions The PCC2 shows promise in assessing ileocolonic mucosa, especially in proximal bowel segments, with greater reach of visualization in the small bowel. Given the resource and safety considerations raised by the Coronavirus disease 2019 pandemic, capsule endoscopy has particular significance. This article aims to contribute to the limited body of research surrounding the validity of capsule endoscopy technology in assessing ileocolonic mucosa in Crohn’s Disease patients. In doing so, an alternative option for patients enduring frequent endoscopies is given potential.

The development of artificial intelligence (AI) has increased dramatically in the last 20 years, with clinical applications progressively being explored for most of the medical specialties. The field of gastroenterology and hepatology, substantially reliant on vast amounts of imaging studies, is not an exception. The clinical applications of AI systems in this field include the identification of premalignant or malignant lesions (e.g., identification of dysplasia or esophageal adenocarcinoma in Barrett’s esophagus, pancreatic malignancies), detection of lesions (e.g., polyp identification and classification, small-bowel bleeding lesion on capsule endoscopy, pancreatic cystic lesions), development of objective scoring systems for risk stratification, predicting disease prognosis or treatment response [e.g., determining survival in patients post-resection of hepatocellular carcinoma), determining which patients with inflammatory bowel disease (IBD) will benefit from biologic therapy], or evaluation of metrics such as bowel preparation score or quality of endoscopic examination. The objective of this comprehensive review is to analyze the available AI-related studies pertaining to the entirety of the gastrointestinal tract, including the upper, middle and lower tracts; IBD; the hepatobiliary system; and the pancreas, discussing the findings and clinical applications, as well as outlining the current limitations and future directions in this field.

Background: Diabetic constipation is traditionally attributed to slow colonic transit, despite limited evidence. More than half of patients find treatment unsatisfactory. To improve treatment, there is a need for better diagnostic understanding of the condition. Objective: In this wireless motility capsule study, we aimed to investigate gastrointestinal transit and contractility in diabetes patients with and without constipation, and in healthy controls. Methods: We prospectively included type 1 or type 2 diabetes patients with gastrointestinal symptoms. Based on the Gastrointestinal Symptom Rating Scale we distinguished into two groups: with constipation and without constipation. Non-diabetic controls were asymptomatic. All were examined with wireless motility capsule, determining transit times and contractility parameters. Results: 57 patients (42 women, 46 with type 1 diabetes) and 26 healthy controls (14 women) were included. We found no difference in transit times between diabetes patients with and without constipation. Compared to healthy controls (35:55, h:min), whole-gut transit was slower in both diabetes patients with constipation (66:15, p = 0.03) and without constipation (71:16, p < 0.001). Small bowel motility index correlated rs = −0.32 (p = 0.01) with constipation symptoms. Conclusions: Diabetes patients with constipation had similar transit times as those without constipation. Both groups had slower whole-gut transit than healthy controls. Constipation was associated with reduced small bowel, but not colonic contractility. Our results imply that other mechanisms than slow colonic transit may be more important in the pathogenesis of diabetic constipation. publishedVersion

BACKGROUND Colon capsule endoscopy (CCE), which became clinically applicable in 2006, is a simple and noninvasive procedure to evaluate colonic diseases; the accuracy of second-generation CCE, introduced in 2009, has dramatically improved. Currently, CCE is used as an alternative method for colorectal cancer screening, as well as for evaluating the mucosal lesions of inflammatory bowel disease, in cases where performing colonoscopy (CS) is difficult. However, the outcomes of CCE are uncertain. AIM To investigate the outcomes of Japanese patients with negative findings (no polyps or colorectal cancer) on initial CCE. METHODS This retrospective, single-center study was conducted at the Endoscopic Center at Aishinkai Nakae Hospital. This study included patients who underwent continuous CCE between November 2013 and August 2019, that exhibited no evidence of polyps or colorectal cancer at the initial CCE, and could be followed up using either the fecal immunochemical test (FIT), CS, or CCE. The observational period, follow-up method, presence or absence of polyps and colorectal cancer, pathological diagnosis, and number of colorectal cancer deaths were evaluated. RESULTS Thirty-one patients (mean age, 60.4 ± 15.6 years; range, 28–84 years; 14 men and 17 women) were enrolled in this study. The reasons for performing the first CCE were screening in 12, a positive FIT in six, lower abdominal pain in nine, diarrhea in two, and anemia in two patients. The mean total water volume at the time of examination was 3460 ± 602 mL (2250–4800 mL), and a total CS was performed in 28 patients (90%). The degree of cleanliness was excellent in 15 patients and good in 16, and no poor cases were observed. No adverse events, such as retention or capsule aspiration, were observed in any of the patients. The mean follow-up period was 3.1 ± 1.5 years (range, 0.3–5.5 years). Follow-up included FIT in nine, CS in 20, and CCE in four patients (including duplicate patients). The FIT was positive in two patients, while CS revealed five polyp lesions (three in the ascending colon, one in the transverse colon, and one in the descending colon), with sizes ranging between 2 mm and 8 mm. Histopathological findings revealed a hyperplastic polyp in one patient, and adenoma with low grade dysplasia in four patients; colorectal cancers were not recognized. In the follow-up example by CCE, polyps and colorectal cancer could not be recognized. During the follow-up period, there were no deaths due to colorectal cancer in any of the patients. CONCLUSION We determined the outcomes in patients with negative initial CCE findings.

BACKGROUND AND AIM The RHEMITT score (Renal disease; Heart failure; Endoscopic findings; Major bleeding; Incomplete SBCE; Tobacco; Treatment by enteroscopy) was the first score to accurately predict the individual risk of small bowel rebleeding after capsule endoscopy (SBCE). The aim of the study is on the prospective validation of the RHEMITT score. METHODS Cohort of consecutive patients with mid-gastrointestinal bleeding (MGIB) submitted to SBCE and followed prospectively, during at least 12 months, since 2017 until 2020. Rebleeding was defined as an overt bleeding event (melena or hematochezia) or a hemoglobin decrease of at least 2 g/dL. The RHEMITT score was calculated for each patient and the rebleeding rates compared. The performance of the score was tested by calculating the area under curve of the receiver operator characteristic curve. A rebleeding-free survival was assessed, corresponding to the period between the date of SBCE and the date of the first post-SBCE rebleeding event. RESULTS We included 162 patients, 102 (62.9%) were female, with a mean age of 64 years old. The sensitivities and specificities of the score grades for predicting rebleeding were as following: for low-risk patients, 0% (0-10%) and 28.8% (21.1-36.5%); for intermediate-risk patients, 23.3% (8.2-38.4%) and 72% (64.3-79.7%); for high-risk patients, 76.7% (61.6-91.8%) and 99.2% (97.7-100%), corresponding to an area under curve of the receiver operator characteristic of 0.988 (P

Systemic sclerosis (SSc) is characterized by fibrosis of the skin and various internal organs. However, there is limited knowledge concerning small-bowel lesions. We evaluated the clinical state of patients with SSc according to the capsule endoscopy (CE) findings. Sixty-five consecutive patients with SSc (61 females; mean age, 64.3 years) underwent CE at Hiroshima University Hospital between April 2012 and December 2019. SSc was subclassified into diffuse and limited cutaneous SSc. Among the 65 patients, 55 (51 females; mean age, 64.5 years; diffuse cutaneous SSc, 27 patients) were evaluated for the presence of fibrosis in the gastrointestinal tract by biopsy. Small-bowel lesions were detected in 27 (42%) patients with SSc. Type 1b angioectasia (Yano-Yamamoto classification) was more frequent in limited cutaneous SSc patients (p = 0.0071). The average capsule transit time of the esophagus was significantly longer in diffuse cutaneous SSc patients (p = 0.0418). There were more cases of Type 1a angioectasia in SSc patients without fibrosis. The average capsule transit time of the esophagus was significantly longer in SSc patients with fibrosis. Thus, this study revealed that the frequency of small-bowel angioectasia and gastrointestinal motility in patients with SSc differed depending on SSc subclassification and the presence of fibrosis.

Összefoglaló. A tápcsatorna endoszkópiája a gasztrointesztinális rendszer betegségeinek legfontosabb vizsgáló eljárása, a diagnosztikán túl egyre szélesedő körben terápiás beavatkozási lehetőséget is magában foglal. A jó minőségben végzett endoszkópia javítja az esetlegesen fennálló betegség kimenetelét és növeli a betegelégedettséget. A nemzetközi emésztőszervi endoszkópos társaságok elsőrendű fontosságúnak határozták meg az endoszkópia minőségének javítását célzó törekvéseket. Az endoszkópos tevékenységek minőségének ellenőrzésében és javításában a meghatározott indikátorok folyamatos követése fontos feladat, ezek révén biztosítható betegeink számára a legmagasabb szintű ellátás. A bizonyítékon alapuló minőségi indikátorok lehetővé teszik az egyes endoszkóposok és az endoszkópos vizsgálóhelyek összehasonlítását és az általuk nyújtott szolgáltatás értékelését. A fenntartónak betegbiztonsági és költséghatékonysági szempontból is fontos ismerni, hogy melyik szolgáltató tudja teljesíteni a minimálisan elvárt és fejlődési célként kitűzött teljesítménymutatókat, melyik ellátónál milyen tényezőket szükséges megváltoztatni, javítani. A szerzők az európai útmutatókat alapul véve a felső tápcsatorna endoszkópiája, az alsó tápcsatorna endoszkópia, a pancreatobiliaris endoszkópia, a vékonybél endoszkópia, a kapszula endoszkópia és az endoszkópos szolgáltatás területén határozták meg a klinikailag releváns teljesítménymutatók auditálható magyar rendszerét. Az egységesség, a jobb digitalizálhatóság és könnyebb auditálhatóság céljából a felső, az alsó, a pancreatobiliaris, a vékonybél és a kapszula endoszkópia vonatkozásában a magyar ajánlásban a minőségi alterületeket egységesen (1–8) számozták, minden szám ugyanazon szempontrendszert jelenti. Az endoszkópos szolgáltatás komplex minőségi mutatóinál szigorúan ragaszkodtak az európai irányelvhez, itt 9 különböző alterületbe foglalták össze a 30 minőségi mutatót. A szűrő kolonoszkópia kiemelt jelentősége miatt a jelen minőségi endoszkópos útmutatóba foglalták bele eltérő szerkezettel a szűrő kolonoszkópos program során alkalmazott minőségi mutatókat, illetve a bélelőkészítést érintő néhány alapvetést is. Summary. Nowadays, endoscopy is the cornerstone in the diagnosis and therapy of gastrointestinal diseases. Good quality endoscopy can improve outcome of the disease and patients experience. International endoscopy societies prioritized efforts improving quality of endoscopy. The highest level of patient care can be provided through continuous assessment and improvement of relevant quality indicators. The comparison of these evidence based performance measures between endoscopists and endoscopy providers allow the objective evaluation of the service. Furthermore, from the point of view of patient safety and cost effectiveness the health care provider should know the minimum standards and target goals, as well, to make grounded decisions about fields of necessary changes and improvements. The authors based on European guidelines worked out this comprehensive auditable Hungarian system of performance measures in the fields of upper endoscopy, lower endoscopy, pancreatobiliary endoscopy, capsule endoscopy, enteroscopy and general endoscopy service. Due to commonality all domains were counted similarly (1–8) in different endoscopic procedures. The general endoscopy service is an exception with 9 domains and 30 quality parameters. The outstanding importance of colorectal cancer screening required involving this topic into this guideline with separate structure, as well as the basics of bowel preparation.

Despite guidelines developed to standardize the diagnosis and management of gastrointestinal (GI) bleeding, significant variability remains in recommendations and practice. The purpose of this survey was to obtain information on practice patterns for the evaluation of overt lower GI bleeding (LGIB) and suspected small bowel bleeding. A 34-question electronic survey was sent to all Society of Abdominal Radiology (SAR) members. Responses were received from 52 unique institutions (40 from the United States). Only 26 (50%) utilize LGIB management guidelines. 32 (62%) use CT angiography (CTA) for initial evaluation in unstable patients. In stable patients with suspected LGIB, CTA is the preferred initial exam at 21 (40%) versus colonoscopy at 24 (46%) institutions. CTA use increases after hours for both unstable (n = 32 vs. 35, 62% vs. 67%) and stable patients (n = 21 vs. 27, 40% vs 52%). CTA is required before conventional angiography for stable (n = 36, 69%) and unstable (n = 15, 29%) patients. 38 (73%) institutions obtain two post-contrast phases for CTA. 49 (94%) institutions perform CT enterography (CTE) for occult small bowel bleeding with capsule endoscopy (n = 26, 50%) and CTE (n = 21, 40%) being the initial test performed. 35 (67%) institutions perform multiphase CTE for occult small bowel bleeding. In summary, stable and unstable patients with overt lower GI are frequently imaged with CTA, while CTE is frequently performed for suspected occult small bowel bleeding.

Background/Aims The diagnosis of small bowel Crohn’s disease with negative ileocolonoscopic findings has been challenging. Fecal calprotectin (FC) has been used to detect colonic inflammation, but its efficacy for detecting small bowel inflammation is less established. We performed an updated meta-analysis to evaluate the diagnostic accuracy of FC to detect active small bowel inflammation observed during capsule endoscopy. Methods We conducted a systematic literature search for studies that evaluated the correlation between small bowel inflammation and FC in patients with suspected/established Crohn’s disease. We calculated the pooled sensitivity, specificity, and diagnostic odds ratios (DORs) and constructed hierarchical summary receiver operating characteristic curves for FC cutoffs of 50, 100, and 200 µg/g. Results Fourteen studies were eligible for the final analysis. The DORs of all FC cutoffs were significant. The highest DOR was observed at 100 µg/g (sensitivity, 0.73; specificity, 0.73; and DOR, 7.89) and was suggested as the optimal diagnostic cutoff. If we analyzed only studies that included patients with suspected Crohn’s disease, the DOR was 8.96. If we analyzed only studies that included patients with a Lewis score ≥135 as a diagnostic criterion for active disease, the DOR was 10.90. Conclusions FC has significant diagnostic accuracy for detecting small bowel inflammation, and an FC cutoff of 100 µg/g can be used as a tool to screen for small bowel Crohn’s disease. (Gut Liver 2021;15-741)

Introducción: el estudio de intestino delgado es un desafío, motivo de avance médico y de interés. La enteroscopia de doble balón (EDB) permite una visualización directa del intestino delgado. Objetivo: describir indicaciones, características del procedimiento, hallazgos, complicaciones y seguimiento de pacientes llevados a EDB en el Hospital de San José de Bogotá, entre noviembre de 2011 y abril de 2019. Metodología: estudio de serie de casos. Se incluyeron pacientes con indicación clínica o por imágenes diagnósticas sugerentes de lesión a nivel de intestino delgado. Se empleó estadística descriptiva. Resultados: se realizaron 45 enteroscopias a 44 pacientes, con una mediana de edad de 58 años. La principal indicación fue hemorragia digestiva potencial de intestino delgado (53,3 %) y diarrea crónica (11,1 %); fueron más frecuentes los procedimientos por vía anterógrada. La mayoría de los resultados fue normal (46,7 %); entre los hallazgos más frecuentes estuvieron los tumores (11,1 %), enfermedad de Crohn (8,9 %) y úlceras/erosiones (6,7 %). El rendimiento diagnóstico fue 53,3 %, la correlación con la videocápsula endoscópica (VCE) fue 37,5 % y con estudios de imagen, 42,9 %. No se presentaron complicaciones. Se hizo seguimiento al 91,1 % de los pacientes con una mediana de 56 meses y se observó la resolución de síntomas en el 78,1 %. La finalidad de la enteroscopia fue diagnóstica en el 84,4 %. Conclusiones: La EDB es útil en la evaluación del intestino delgado con posibilidad terapéutica. Los resultados son similares a los reportados en la literatura mundial. Si se realiza seguimiento, se puede definir la necesidad de repetición del procedimiento, realización de estudios adicionales u observar resolución de los síntomas.

El adenocarcinoma de yeyuno es el tumor primario del intestino delgado más infrecuente y raro, y representa el 3 % de todos los cánceres gastrointestinales, con una incidencia anual estimada de 0,3 a 2 casos por cada 100 000 personas. En Estados Unidos y España representa el 0,4 % de los cánceres gastrointestinales y el 0,2 % de las muertes asociadas a malignidad, con síntomas inespecíficos como anemia de etiología inexplicable, dolor abdominal y pérdida de peso; la mayoría de ellos son diagnosticados en etapas avanzadas de la enfermedad. A continuación, se presenta el caso de una paciente femenina de 46 años con síntomas inespecíficos, pérdida de peso, dolor abdominal y vómito, cuya tomografía abdominal computarizada evidenció el sitio y extensión de la lesión neoplásica, mientras que la cápsula endoscopia y enteroscopia mostró una lesión neoplásica en el yeyuno proximal. La histopatología reportó un adenocarcinoma de yeyuno moderadamente diferenciado que presentó resultados favorables gracias a la resección quirúrgica curativa, lo cual mejoró el pronóstico de vida a 5 años y tuvo un seguimiento favorable hasta la actualidad.

BACKGROUND AND AIM We retrospectively determined the safety and efficacy of the endoscopic delivery (ED) of capsule endoscopes. METHODS We enrolled 10,156 patients who underwent small bowel capsule endoscopy (SBCE), 3182 who underwent patency capsule (PC), and 1367 who underwent colon capsule endoscopy (CCE), at 11 gastroenterological and nine pediatric centers. RESULTS Small bowel capsule endoscopies, PCs, and CCEs were endoscopically delivered to 546 (5.4%), 214 (6.7%), and 14 (1.0%) patients, respectively. Only mild complications occurred for 21.6% (167/774), including uneventful mucosal damage, bleeding, and abdominal pain. Successful ED of SBCE to the duodenum or jejunum occurred in 91.8% and 90.7% of patients aged

Colon capsule endoscopy (CCE) is a minimally invasive alternative for patients unwilling to undergo conventional colonoscopy, or for whom the latter exam is contraindicated. This is particularly important in the setting of colorectal cancer screening. Nevertheless, these exams produce large numbers of images, and reading them is a monotonous and time-consuming task, with the risk of overlooking important lesions. The development of automated tools based on artificial intelligence (AI) technology may improve some of the drawbacks of this diagnostic instrument. A database of CCE images was used for development of a Convolutional Neural Network (CNN) model. This database included anonymized images of patients with protruding lesions in the colon or patients with normal colonic mucosa or with other pathologic findings. A total of 3,387,259 frames from 24 CCE exams were retrospectively reviewed. For CNN development, 3640 images (860 protruding lesions and 2780 with normal mucosa or other findings) were ultimately extracted. Training and validation datasets were constructed for the development and testing of the CNN. The CNN detected protruding lesions with a sensitivity, specificity, positive and negative predictive values of 90.7, 92.6, 79.2 and 96.9%, respectively. The area under the receiver operating characteristic curve for detection of protruding lesions was 0.97. The deep learning algorithm we developed is capable of accurately detecting protruding lesions. The application of AI technology to CCE may increase its diagnostic accuracy and acceptance for screening of colorectal neoplasia.

Sprue-like enteropathy associated with olmesartan is characterized by villous atrophy in the duodenum. We report the case of an 81-year-old woman diagnosed with olmesartan-associated sprue-like enteropathy with no villous atrophy in the duodenum. The patient had been taking olmesartan for 10 years and complained of diarrhea and weight loss. Despite undergoing general treatment for 2 months, her symptoms showed no improvement. Gastrointestinal endoscopy and pathological findings showed no villous atrophy in the duodenum. However, villous atrophy was observed in the small intestine by capsule endoscopy. Pathological biopsy with double balloon endoscopy provided a definitive diagnosis. Diarrhea improved with the discontinuation of olmesartan and weight increased within a week of withdrawal. After the improvement of clinical symptoms, both endoscopic and pathological findings of villous atrophy in small intestine showed improvement.

Recently, the coronavirus disease 2019 (COVID‐19) has caused a global pandemic. Several studies indicate that the digestive system can also be affected by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Therefore, patients with digestive symptoms should have a capsule endoscopy (CE). COVID‐19 patients with gastrointestinal (GI) symptoms who underwent CE were recruited from March 2020 to April 2020. We collected patients’ data and performed a prospective follow‐up study for 6 months. All 11 COVID‐19 cases with GI symptoms who underwent CE presented gastritis. Eight cases (72.7%) had intestinal mucosa inflammation. Among them, two cases showed intestinal ulcers or erosions. Moreover, two cases displayed colonic mucositis. One case was lost during follow‐up. At 3–6 months after hospital discharge, five patients underwent CE again, presenting gastrointestinal lesions. Five of the 10 cases had GI symptoms, such as abdominal pain, diarrhea, constipation, and others. Among these five cases, the GI symptoms of three patients disappeared at the last follow‐up and two patients still presented diarrhea symptoms. Overall, we observed damaged digestive tract mucosa that could be caused by SARS‐CoV‐2. Moreover, after discharge, some patients still presented intestinal lesions and GI symptoms.

Background and aim: Capsule endoscopy is the most sensitive method for evaluating mucosal lesions in Crohn’s Disease and recent studies show that capsule endoscopy could be used for disease staging and for careful monitoring to evaluate endoscopic activity on a regular basis. Over time, many platelet changes have been described in IBD, including morphological and functional alteration and increased number. We determined whether platelets count correlates with the endoscopic activity measured using capsule endoscopy in Crohn’s disease patients from a single center. Methods: This is a retrospective observational study. There were enrolled patients with suspected or known Crohn’s disease that underwent evaluation with capsule endoscopy in our department, between 2011 and 2021. For the evaluation with capsule endoscopy, Pillcam SB3 or Pillcam Colon2 were used. For the evaluation of endoscopic activity, we used Lewis score calculated using RAPID 8 capsule reading software. Platelets level was measured and correlated with the Lewis score, inflammatory biomarkers (C-reactive protein and fecal calprotectin) and anemic syndrome. Results: A total of 62 patients were included in the study, of whom 37 (59.67%) were with suspected Crohn’s disease and 25 (40.32%) were with known Crohn’s disease. Thrombocytosis was present in the majority of patients with severe endoscopic activity (Lewis score more than 790), elevated CRP, fecal calprotectin more than 250microg/g and anemic syndrome. Conclusion: To our knowledge, this is the first study that assess the correlation between thrombocytosis and severity of Crohn’s disease, evaluated with capsule endoscopy. Our data suggests that platelet count is a valuable, non-invasive, easy to use biomarker that is a good predictor of severity of Crohn’s disease and could have a prognostic value. It correlates well with Lewis score, CRP, fecal calprotectin and anemia.

Background Meckel's diverticulum is a common asymptomatic congenital gastrointestinal anomaly. However, its presentation as an inverted Meckel's diverticulum is a rare complication, of which few cases have been reported in the literature. Case summary Here, we report the case of a 33-year-old man with iron deficiency anemia without manifestation of gastrointestinal bleeding. An upper gastrointestinal endoscopy and total colonoscopy were performed, but no abnormalities were found within the observed area. Finally, a capsule endoscopy was performed and offered us a clue to subsequently confirm the diagnosis of inverted Meckel's diverticulum via computed tomography scan. Laparoscopic intestinal resection surgery was performed. The final pathology report described a Meckel's diverticulum. Conclusion Since inverted Meckel's diverticulum is an uncommon disease and its clinical presentation is not specific, it may go undetected by capsule endoscopy. Successful diagnosis and treatment of this disease requires a high index of clinical suspicion.

Background Fetomaternal outcomes are of primary concern for gastrointestinal (GI) endoscopy in pregnancy. We aimed to systematically review the safety and utility of endoscopic procedures in pregnancy. Methods A systematic literature search was performed using PubMed. All original research articles with sample size > 10 involving endoscopy in pregnancy were included for the review along with case report/series describing novel/rare techniques from 1948 to July 2021. Results After screening 12,197 references, 216 citations were found and finally 66 references were included. Esophagogastroduodenoscopy had favorable fetal outcome (>95%) based on two large retrospective studies and a review of case reports. Sclerotherapy and band ligation of varices were safe according to case series. A large nationwide cohort study established safety of endotherapy for nonvariceal bleed. Botulinum toxin and pneumatic dilation in achalasia are only supported by case reports. Percutaneous endoscopic gastrostomy can be useful to support nutrition based on case reports. A retrospective case–control and cohort study with systemic review justified flexible sigmoidoscopy if strongly indicated. Low birth weight was more common when sigmoidoscopy was done in inflammatory bowel disease based on a prospective study. Colonoscopy was considered safe in second trimester based on a case–control study whereas it can be performed otherwise only in presence of strong indication like malignancy. Capsule endoscopy is promising and can be useful in acute small bowel bleeding although risk of capsule retention is unknown. There are no reports of enteroscopy in pregnancy. Twelve retrospective studies and one prospective study showed high success rate of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (> 90%) in all trimesters and can be performed if strongly indicated. Pregnancy was an independent risk factor for post-ERCP pancreatitis in a large nationwide case–control study. Radiation-free ERCP with wire-guided bile observation, stent-guided or precut sphincterotomy, endoscopic ultrasound (EUS) guidance, and spyscopy have been described. Safety of EUS is limited to case series and can be used in intermediate probability of choledocholithiasis to guide ERCP and endoscopic cystogastrostomy. Conclusion This review concludes that GI endoscopy during pregnancy can be done effectively if strongly indicated with good fetomaternal outcomes. Precautions are advocated during procedures where radiation exposure is expected.

OBJECTIVES Deep remission should be induced early in the disease course of Crohn's disease (CD), because it significantly prevents disease progression. Identifying predictors of deep remission before treatment is important to guide therapeutic strategy. Little is known about the predictors of infliximab-induced deep remission in treatment-naive patients with isolated small bowel CD. We aimed to investigate the predictors of infliximab-induced deep remission in these patients. MATERIALS AND METHODS From January 2015 to December 2019, all consecutive treatment-naive patients with isolated small bowel CD who started infliximab induction therapy (5 mg/kg at week 0, 2, and 6) and underwent capsule endoscopy (CE) at week 14 were retrospectively included. Deep remission was defined as clinical remission in combination with CE-identified mucosal healing. Logistic regression was used to investigate the predictors of 14-week deep remission. RESULTS Ninety-one patients were included. At week 14 after infliximab induction therapy, deep remission was found in 42 patients. Multivariate logistic regression analysis showed that a moderate-to-severe endoscopic disease [odds ratio (OR), 0.28; p = .01] and the presence of fibrofatty proliferation (OR, 0.26; p = .04) at baseline were independently associated with a decreased possibility of deep remission. CONCLUSIONS In treatment-naive patients with isolated small bowel CD, a moderate-to-severe endoscopic disease and the presence of fibrofatty proliferation at baseline reduce the possibility of infliximab-induced deep remission. Patients with such risk factors may need more aggressive treatment at the beginning of induction therapy to promote deep remission at an early stage.

Background Wireless capsule endoscopy (WCE) is considered to be a powerful instrument for the diagnosis of intestine diseases. Convolution neural network (CNN) is a type of artificial intelligence that has the potential to assist the detection of WCE images. We aimed to perform a systematic review of the current research progress to the CNN application in WCE. Methods A search in PubMed, SinoMed, and Web of Science was conducted to collect all original publications about CNN implementation in WCE. Assessment of the risk of bias was performed by Quality Assessment of Diagnostic Accuracy Studies-2 risk list. Pooled sensitivity and specificity were calculated by an exact binominal rendition of the bivariate mixed-effects regression model. I2 was used for the evaluation of heterogeneity. Results 16 articles with 23 independent studies were included. CNN application to WCE was divided into detection on erosion/ulcer, gastrointestinal bleeding (GI bleeding), and polyps/cancer. The pooled sensitivity of CNN for erosion/ulcer is 0.96 [95% CI 0.91, 0.98], for GI bleeding is 0.97 (95% CI 0.93–0.99), and for polyps/cancer is 0.97 (95% CI 0.82–0.99). The corresponding specificity of CNN for erosion/ulcer is 0.97 (95% CI 0.93–0.99), for GI bleeding is 1.00 (95% CI 0.99–1.00), and for polyps/cancer is 0.98 (95% CI 0.92–0.99). Conclusion Based on our meta-analysis, CNN-dependent diagnosis of erosion/ulcer, GI bleeding, and polyps/cancer approached a high-level performance because of its high sensitivity and specificity. Therefore, future perspective, CNN has the potential to become an important assistant for the diagnosis of WCE.

Objective CT enterography/enteroclysis (CTE) is listed in the clinical practice guidelines as a method for diagnosing small bowel bleeding, as is capsule endoscopy (CE), but there are no real-world data yet available on CTE in Japan. This study aimed to investigate the diagnostic ability of CTE and long-term prognosis after CTE in Japan. Patients We conducted a retrospective cohort study of patients suspected of having small bowel bleeding who underwent both CTE and CE within 30 days between April 2008 and March 2019. The number of patients free from rebleeding for up to 24 months was thus determined. Results Seventy-one patients were extracted from the database. The 43 patients (60.6%) with a definite and suspicious source of bleeding in the small bowel were detected by CTE. When the 31 patients with a definite source of bleeding in the small bowel were analyzed, the sensitivity of CTE was 19/31 (61.3%) and that of CE was 24/31 (77.4%), thus indicating no significant difference (p=0.332). However, the sensitivity when CTE and CE were used in combination was 30/31 (96.8%), which was significantly higher than that of CE alone (p=0.0412). No rebleeding was observed in the CTE and CE negative group (p=0.0965). Conclusion The combined use of CTE and CE increased the detection rate of small bowel bleeding. Therefore, in patients with suspected tumor/polyp lesions, not only CE, but also CTE should be performed. This study provides the first real-world data on the diagnostic accuracy of CTE for small bowel bleeding in Japan.

Background and aims Capsule endoscopy (CE) interpretation requires the review of many thousands of images, with lesions often limited to just a few frames. In this study we aim to determine whether lesion detection declines according to the number of capsule videos read. Methods 32 participants, 16 of which were novices (NR) and 16 experienced (ER) capsule readers took part in this prospective evaluation study. Participants read six capsule cases with a variety of lesions, in a randomly assigned order during a single sitting. Psychomotor Vigilance Tests and Fatigue Scores were recorded prior to commencing and then after every two capsules read. Changes in lesion detection and measures of fatigue were assessed across the duration of the study. Results Mean agreement with the predefined lesions was 48.3% (SD:16.1), and 21.3% (SD:15.1) for the experienced and novice readers respectively. Lesion detection declined amongst experienced reader after the first study (p = 0.01), but remained stable after subsequent capsules read, while NR accuracy was unaffected by capsule numbers read. Objective measures of fatigue did not correlate with reading accuracy. Conclusion This study demonstrates that reader accuracy declines after reading just one capsule study. Subjective and objective measures of fatigue were not sufficient to predict the onset of the effects of fatigue.

Mark Hanscom Courtney Stead Harris Feldman Neil B. Marya David Cave.

The current study evaluated the application of small-bowel capsule endoscopy (SBCE) in SARS-CoV-2-infected patients with suspected small bowel bleeding. We analyzed the clinical characteristics, SBCE procedures, examination results, and treatment for cases of suspected small bowel bleeding in two patients with critical COVID-19. SBCE showed active spotting bleeding in the jejunum and ileum with no identifiable lesions in case 1, while multiple small bowel ulcers were detected in case 2. Two patients had relevant changes in their management plans and received specific treatment based on SBCE findings. In summary, SBCE proved to be a non-invasive diagnostic tool for critical COVID-19 patients with suspected small bowel bleeding.

It is often difficult to explain why ulcerative lesions are found in the small intestine because there are no obvious aggressors such as gastric acid. In particular, the treatment of small intestinal ulcerative lesions in asymptomatic patients with no symptoms, normal physical examinations, and normal blood test findings is not well documented. According to a summary of capsule endoscopy studies in healthy subjects, approximately 10% of subjects have small intestinal mucosal breaks. The number of mucosal breaks in these instances is approximately 1-3. We examined small intestinal mucosal breaks in healthy subjects recruited from our past two studies. Mucosal breaks were observed in approximately 10% of subjects, and the average number was 0.24 ± 1.21. The number of mucosal breaks in the small intestine was correlated with body mass index and was significantly higher in Helicobacter pylori-infected subjects and higher in males. These results indicate that 1-2 small ulcerative lesions, such as erosions in the small intestine, can be considered to be in the normal range, and close examination is not required. It is assumed that a follow-up medical examination is required for such asymptomatic persons. The presence of many small ulcerative lesions or an unequivocal ulcer indicates an abnormality for which close examination is desired. However, in many cases, it is sufficient to scrutinize after detecting anemia, but it is difficult to make a judgment due to insufficient reports, and future studies are required.

BACKGROUND Preparation for colon capsule endoscopy (CCE) requires a large liquid laxative volume for capsule excretion, which compromises the procedure's tolerability. AIM To assess the safety and utility of castor oil-boosted bowel preparation. METHODS This prospective cohort study including 20 patients (age range, 16-80 years; six men and 14 women) suspected of having colorectal disease was conducted at Kindai University Hospital from September 2017 to August 2019. All patients underwent CCE because of the following inclusion criteria: previous incomplete colonoscopy in other facility (n = 20), history of abdominal surgery (n = 7), or organ abnormalities such as multiple diverticulum (n = 4) and adhesion after surgery (n = 6). The exclusion criteria were as follows: Dysphagia, history of allergic reactions to the drugs used in this study (magnesium citrate, polyethylene glycol, metoclopramide, and castor oil), possibility of pregnancy, possibility of bowel obstruction or stenosis based on symptoms, or scheduled magnetic resonance imaging within 2 wk after CCE. The primary outcome was the capsule excretion rate within the battery life, as evaluated by the total large bowel observation rate, large bowel transit time, and bowel creasing level using a five-grade scale in different colorectal segments. The secondary outcomes were complications, colorectal lesion detection rates, and patients’ tolerability. RESULTS The castor oil-based regimen was implemented in 17 patients. Three patients cancelled CCE because they could tolerate castor oil, but not liquid laxatives. The capsule excretion rate within the battery life was 88% (15/17). The mean large bowel transit time was 236 min. Approximately 70% of patients had satisfactory colon cleansing levels. CCE detected colon polyps (14/17, 82%) and colonic diverticulum (4/12, 33%). The sensitivity, specificity, and diagnostic accuracy rates for detecting colorectal polyps (size ≥ 6 mm) were 76.9%, 75.0%, and 76.4%, respectively. The sensitivity, specificity, and diagnostic accuracy rates for detection of diverticulum were 100% each. Twelve patients (71%) rated CCE as more than “good”, confirming the new regimen’s tolerability. No serious adverse events occurred during this study. CONCLUSION The castor oil-based regimen could reduce bowel preparation dose and improve CCE tolerability.

In recent years, panintestinal capsule endoscopy (PCE) with double-headed capsules has been used to perform complete, single-sitting exploration of both small bowel and colon in different clinical conditions. Double-headed capsules for colonic examination (CCE) have been exploited first in this setting, followed by newer generations of capsules (i.e. PillCam Crohn, PCC) specifically engineered for this purpose. The aim of this study was to evaluate the feasibility of PCE in the form of a systematic review. We performed a comprehensive literature search to identify papers in which CE was specifically used for a PCE of the gastrointestinal tract. Data on CE, bowel preparation regimen, rate of cleanliness and completeness, and data on transit times were analyzed. The primary outcome was to assess the feasibility of a whole-gut exploration with CE. Sixteen (n = 16) studies including 915 CE procedures with CCE1 (n = 134), CCE2 (n = 357) and PCC (n = 424) were included. 13/16 studies were performed in the setting of Crohn's disease. Cleanliness and completeness rates were acceptable in all studies, ranging from 63.9% and 68.6% to 100%, respectively. In conclusion, PCE is a feasible technique, although further structured studies are needed to explore its full potential.

A 74-year-old male with a history of metastatic melanoma presents with persistently abnormal small bowel findings on PET-CT scan. The patient had persistent FDG uptake near the ileocolic junction on imaging, concerning for metastatic melanoma. Capsule endoscopy demonstrated ulcerated mucosa in the distal ileum. This area was biopsied and tattooed via retrograde double-balloon enteroscopy to confirm the diagnosis of metastatic melanoma and facilitate subsequent small bowel resection. The case illustrates a unique case of metastatic melanoma to the small bowel and the utility of capsule endoscopy and balloon-assisted enteroscopy to assist in diagnosis and management of metastatic disease.

INTRODUCTION Capsule endoscopy has proven its utility in diagnosing villous atrophy and lymphoma in patients with celiac disease. Recently, a novel capsule endoscopy system was introduced which enables the examination of the small and large bowel. So far, it has not been evaluated in patients with celiac disease. OBJECTIVE The primary objective of this study was to evaluate the novel panintestinal capsule endoscopy system in patients with celiac disease. METHODS Eleven patients with histologically proven celiac disease (Marsh 0-IV), who underwent a panintestinal capsule endoscopy between March 2018 and April 2019 at our institution, were included in this retrospective single-center study. All patients performed standard bowel preparation prior to the examination. Diagnostic yield, safety and therapeutic impact were analyzed. In addition, the correlation between capsule endoscopy findings and the histology of the duodenal mucosa was assessed. RESULTS Panintestinal capsule endoscopy was feasible and produced an acceptable visualization quality in all cases. Concordance of capsule endoscopy findings with the Marsh classification showed a good correlation (r = 0.8). No lymphomas were detected. Evaluation of the colon revealed diminutive polyps (median size 4 mm) in 18% of patients. CONCLUSIONS The novel panintestinal capsule endoscopy system shows a fair correlation with the Marsh classification in patients with celiac disease. It is also capable of identifying colon polyps. Therefore, the novel panintestinal capsule endoscopy system can be considered for patients with celiac disease and an indication for capsule endoscopy.

The diagnostic yield (DY) of small-bowel capsule endoscopy (SBCE) varies considerably according to its indication. Some strategies have been used to increase DY with varying results. The intention of this study was to identify whether evaluation of the SBCE recordings by a second reviewer can increase DY and change patient management.One hundred SBCEs with different indications, already read by an endoscopist were read by a second blinded endoscopist. When the results of the 2 readings were different, the images were discussed by the endoscopists; if no consensus was reached, they took the opinion of a third endoscopist into account. All the participating endoscopists had experience in reading SBCEs (i.e.,50 per year). The SBCE findings were divided into positive (vascular lesions, ulcers, and tumors), equivocal (erosions or red spots), and negative. The interobserver agreement and the increase in DY were assessed as well as the percentage of false-negatives (FNs) in the first evaluation.The indications for SBCE were small-bowel bleeding (SBB) in 48 cases, Crohn's disease (CD) in 30, and other causes (iron-deficiency anemia, small-bowel tumors, and diarrhea) in 22. There was substantial interobserver agreement between evaluations (κ = 0.79). The findings in the first evaluation were positive in 60%, equivocal in 20% and, negative in 20%. In the second evaluation, 66% were positive, 18% were equivocal, and 16% were negative. The increase in DY with the second reading was 6% (A second evaluation of the SBCE recordings identified significant pathology that the first evaluation had missed, resulting in a nonsignificant 6% increase in DY and a change in the management of 4% of the patients.O rendimento diagnóstico (DY) da enteroscopia por cápsula (SBCE) varia consideravelmente de acordo com as suas indicações. Foram estudadas algumas estratégias para melhorar o DY, com resultados variados. O objetivo deste estudo é avaliar se uma segunda leitura de registos de enteroscopia por cápsula por um segundo endoscopista pode melhorar o DY e alterar o manejo dos doentes.100 SBCE realizadas por indicações variadas, previamente avaliadas por um endoscopista, foram reavaliadas por um segundo endoscopista cego para a primeira leitura. Na presença de resultados discordantes nas 2 leituras, as imagens foram discutidas pelos 2 endoscopistas, e por um terceiro na ausência de consenso entre os 2 primeiros. Todos os endoscopistas são experientes na leitura de SBCE (50 SBCE/ano). Os achados foram categorizados em positivos (lesões vasculares, úlceras e tumores), equívocos (erosões e pontos vermelhos) e negativos. Foi avaliada a concordância inter-observador e o aumento do DY, bem como a percentagem de falsos negativos da primeira avaliação.As indicações para SBCE foram hemorragia do intestino delgado (SBB) em 48 casos, doença de Crohn (CD) em 30 e outras causas (anemia por défice de ferro, pesquisa de tumores do intestino delgado e diarreia) em 22. A concordância inter-observador foi substancial (k = 0.79). Os achados da primeira avaliação foram positivos em 60%, equívocos em 20% e negativos em 20%, enquanto na segunda avaliação foram positivos em 66%, equívocos em 18% e negativos em 16%. O aumento de DY foi de 6% com a segunda leitura (A segunda avaliação dos registos de SBCE identificou patologia significativa previamente não identificada, resultando num aumento não significativo de 6% do DY e numa alteração no manejo de 4% dos doentes.

To investigate the effects of Weikang Capsule (胃康胶囊, WKC) on aspirin-related gastric and small intestinal mucosal injury by magnetically controlled capsule endoscopy (MCCE). Patients taking enteric-coated aspirin aged 40–75 years were enrolled in Beijing Anzhen Hospital, Capital Medical University from January 2019 to December 2019. The patients continued taking aspirin Tablet (100 mg per day) and underwent MCCE before and after 1-month combined treatment with WKC (0.9 g per time orally, 3 times per day). The gastrointestinal symptom score, gastric Lanza score, the duodenal, jejunal and ileal mucosal injury scores were used to evaluate the gastrointestinal injury before and after treatment. Adverse events including nausea, vomiting, abdominal pain, abdominal distension, abdominal discomfort, dizziness, or headache during MCCE and combined treatment were observed and recorded. Twenty-two patients (male/female, 13/9) taking enteric-coated aspirin aged 59.5 ± 11.3 years with a duration of aspirin use of 28.0 (1.0, 48.0) months were recruited. Compared with pre-treatment, the gastrointestinal symptom rating scale scores, gastric Lanza scores, and duodenal mucosal injury scores were significantly reduced after 1-month WKC treatment (P

Background With recent advances in endoscopic modalities, small bowel vascular lesions (SBVLs) are often now detected in patients with gastrointestinal bleeding. Given the high invasiveness of endoscopic treatment, it is important to select patients at high risk for bleeding. Aim To assess the risk of rebleeding in patients with SBVLs as a systemic disease rather than a gastrointestinal disease in relation to their general health. Methods We retrospectively analyzed the clinical data of 55 patients with SBVLs among patients with obscure gastrointestinal bleeding. The possible association between the clinical findings and the updated Charlson comorbidity index with rebleeding was evaluated. Results Gastrointestinal rebleeding occurred in 20 patients (36.4%) during the follow-up period. The presence of multiple comorbidities as indicated by an updated Charlson comorbidity index of ≥4 was a risk factor for rebleeding (hazard ratio, 3.64; P = 0.004). Other risk factors were arteriosclerosis of the superior mesenteric artery and multiple SBVLs. Endoscopic hemostasis and the discontinuation of antithrombotic medications were not significantly associated with rebleeding. Patients with a high updated Charlson comorbidity index had a high risk of death of causes other than gastrointestinal rebleeding. Conclusions Gastrointestinal rebleeding is not a rare condition among patients with SBVLs. Patients with poor general health may therefore have a higher risk of rebleeding.