Capsule Endoscopy in Tamworth. True or False: “Capsule Endoscopy is a useful test in the diagnosis of unexplained anaemia” FALSE

Capsule Capsule EndoscopyEndoscopy

in Tamworth in Tamworth

True or False: True or False: “Capsule “Capsule

Endoscopy is a Endoscopy is a useful test in the useful test in the

diagnosis of diagnosis of unexplained unexplained

anaemia”anaemia”FALSEFALSE

Importance of Pre Test Importance of Pre Test ProbabilityProbability

MBS – Item Number 11820MBS – Item Number 11820 obscure gastrointestinal bleedingobscure gastrointestinal bleeding, using a capsule endoscopy , using a capsule endoscopy

device approved by the Therapeutic Goods Administration (including device approved by the Therapeutic Goods Administration (including administration of the capsule, imaging, image reading and interpretation, administration of the capsule, imaging, image reading and interpretation, and all attendances for providing the service on the day the capsule is and all attendances for providing the service on the day the capsule is administered), (not being a service associated with double balloon administered), (not being a service associated with double balloon enteroscopy), if: enteroscopy), if: (a) the service is performed by a specialist or consultant physician (a) the service is performed by a specialist or consultant physician

with endoscopic training that is recognised by The Conjoint with endoscopic training that is recognised by The Conjoint Committee for the Recognition of Training in Gastrointestinal Committee for the Recognition of Training in Gastrointestinal Endoscopy; and Endoscopy; and

(b) the patient to whom the service is provided: (b) the patient to whom the service is provided: (i) is aged 10 years or over; and (i) is aged 10 years or over; and (ii) has (ii) has recurrent or persistent bleedingrecurrent or persistent bleeding; and ; and (iii) is (iii) is anaemic or has active bleedinganaemic or has active bleeding; and ; and

(c) an (c) an upper gastrointestinal endoscopy and a upper gastrointestinal endoscopy and a colonoscopy have been performed on the patient and colonoscopy have been performed on the patient and have not identified the cause of the bleedinghave not identified the cause of the bleeding; and ; and

(d) (d) the service is performed within 6 months of the the service is performed within 6 months of the upper gastrointestinal endoscopy and colonoscopyupper gastrointestinal endoscopy and colonoscopy

Understanding the “O’s” of Understanding the “O’s” of GI BleedingGI Bleeding

ObscureObscure Cause not identified after endoscopies Cause not identified after endoscopies

(up to10% - 75% will be due to small bowel lesions)(up to10% - 75% will be due to small bowel lesions)

OvertOvert Melaena or haematocheziaMelaena or haematochezia

OccultOccult Not OvertNot Overt

In practice, obscure GI bleeding is eitherovert or causes iron deficiency

Diagnosing Iron Diagnosing Iron DeficiencyDeficiencyIron Iron

DeficiencDeficiencyy

Systemic Systemic DiseaseDisease

MixedMixed

IronIron ↓↓ ↓↓ ↓↓TransferriTransferrinn

↑↑ ↓↓ ↓↓

TransferriTransferrin n SaturationSaturation

↓ ↓↓ ↓ ↓ ↓ / N / ↑/ N / ↑ ↓↓

FerritinFerritin ↓ ↓ ↑↑ ↓ ↓ / N / ↑/ N / ↑TransferriTransferrin Receptorn Receptor

↑↑ NN ↑↑

Initial Iron Deficiency Initial Iron Deficiency WorkupWorkup

Consider ExtraIntestinal CausesConsider ExtraIntestinal Causes DietaryDietary Pregnancy, LactationPregnancy, Lactation MenstruationMenstruation HaemolysisHaemolysis Blood donationBlood donation HaematuriaHaematuria


Consider ExtraIntestinal CausesConsider ExtraIntestinal Causes GastroscopyGastroscopy

Ulcers, Malignancy, Angioectasia, GAVEUlcers, Malignancy, Angioectasia, GAVE H. Pylori H. Pylori statusstatus Duodenal biopsies for coeliac diseaseDuodenal biopsies for coeliac disease

ColonoscopyColonoscopy Malignancy, colitis, angioectasia, Malignancy, colitis, angioectasia,

proctitisproctitis Include ileoscopyInclude ileoscopy Good bowel preparation importantGood bowel preparation important


If Endoscopies are non-diagnostic:If Endoscopies are non-diagnostic: Reconsider extraintestinal causesReconsider extraintestinal causes Consider Urinalysis and Coeliac disease Consider Urinalysis and Coeliac disease

serologyserology

Iron Replacement OR Early Capsule Iron Replacement OR Early Capsule EndoscopyEndoscopy

Iron Replacement OR Iron Replacement OR Early Capsule EndoscopyEarly Capsule Endoscopy

Iron ReplacementIron Replacement YoungerYounger PremenopausalPremenopausal AsymptomaticAsymptomatic Never overt bleedingNever overt bleeding

Observe for at least 3 Observe for at least 3 months then recheck months then recheck Hb and ferritin. If Hb and ferritin. If “recurrent or persistent “recurrent or persistent bleeding”, then capsule bleeding”, then capsule endoscopyendoscopy

Early Capsule Early Capsule EndoscopyEndoscopy OlderOlder MaleMale Symptoms, Weight lossSymptoms, Weight loss Any overt bleedingAny overt bleeding

Need to demonstrate Need to demonstrate “recurrent or persistent “recurrent or persistent bleeding” – eg 2 low bleeding” – eg 2 low Hb’s, a positive FOBT Hb’s, a positive FOBT after endoscopies etcafter endoscopies etc

Capsule Endoscopy Capsule Endoscopy PreparationPreparation

Similar to colonoscopySimilar to colonoscopy Stop iron tablets 5 days priorStop iron tablets 5 days prior Clear fluids afternoon beforeClear fluids afternoon before 2 sachets of PicoPrep2 sachets of PicoPrep 10 hour fast10 hour fast

On the dayOn the day Metoclopramide and simethiconeMetoclopramide and simethicone

What Does Capsule Endoscopy What Does Capsule Endoscopy Visualize in the Small Bowel?Visualize in the Small Bowel?

Melanoma Inflammation by infection (eg, CMV)

Angioectasia Inflammatory stenosis

Overt bleeding Mass/tumor Ulcerated stenosis caused by NSAID use

Bleeding ulcer

Yield of Capsule Yield of Capsule EndoscopyEndoscopy

38 – 83%38 – 83% Depends largely on pre test Depends largely on pre test

probabilityprobability Of small bowel lesions found:Of small bowel lesions found:

60% angioectasia60% angioectasia 30% ulcers / erosions30% ulcers / erosions 10% tumours10% tumours

Other Diagnostic OptionsOther Diagnostic Options

MethodMethod Diagnostic YieldDiagnostic Yield ConsiderationsConsiderations

Standard Standard Radiological ImagingRadiological Imaging

• Low: 5% (unable to Low: 5% (unable to diagnose most vascular diagnose most vascular lesions)lesions)

• Impact on management: <10%Impact on management: <10%•Useful for clinical suspicion of small bowel Useful for clinical suspicion of small bowel obstruction, tumorsobstruction, tumors

Bleeding ScanBleeding Scan• Low: ~25%Low: ~25%• Location accuracy:Location accuracy: ~30–50% ~30–50%

• Sensitivity threshold: 0.3 mL/minSensitivity threshold: 0.3 mL/min• Prerequisite to angiographyPrerequisite to angiography• Time-consumingTime-consuming• Little or no benefit in typical OGIBLittle or no benefit in typical OGIB

AngiographyAngiography • Low: 25%–30%Low: 25%–30%• Sensitivity threshold: 0.5 mL/hSensitivity threshold: 0.5 mL/h• InvasiveInvasive• Identifies bleeding/non-bleedingIdentifies bleeding/non-bleeding lesions lesions

Double-Balloon Double-Balloon EnteroscopyEnteroscopy • 60%–80%60%–80%

• Time-consumingTime-consuming• Requires extensive training; additional Requires extensive training; additional nursing staff, anesthesiological support often nursing staff, anesthesiological support often requiredrequired• Optimal patient selection requiredOptimal patient selection required

Diagnostic Options Diagnostic Options (continued)(continued)

MethodMethod Diagnostic YieldDiagnostic Yield ConsiderationsConsiderations

Intraoperative Intraoperative EnteroscopyEnteroscopy

• 70%–100%70%–100% • Transfusion-dependent (severe blood loss)Transfusion-dependent (severe blood loss)

• Risk of continued bleeding (outweighs risk of therapy)Risk of continued bleeding (outweighs risk of therapy)

• Technically difficultTechnically difficult

• Adhesions, luminal blood, infiltrating neoplasiaAdhesions, luminal blood, infiltrating neoplasia

• Complications (during and after procedure)Complications (during and after procedure)

CT Enterography CT Enterography • Low: vascular Low: vascular malformations, malformations, ulcerative diseaseulcerative disease

• ~20% of submucosal lesions missed~20% of submucosal lesions missed

Push Push Enteroscopy Enteroscopy

• 15%–35% average15%–35% average

• Variable for overt Variable for overt bleeding and AVMs: bleeding and AVMs: 5%–65% 5%–65%

• May detect missed proximal lesionsMay detect missed proximal lesions

• Provides opportunity to identify and treat active Provides opportunity to identify and treat active bleeding (AVMs only) 25%– 85% of the time within a bleeding (AVMs only) 25%– 85% of the time within a single yearsingle year

Small Bowel CESmall Bowel CE • 38%–83%38%–83% • Affects change in management in ≥87% of patients Affects change in management in ≥87% of patients (50%–66% remain transfusion-free)(50%–66% remain transfusion-free)

• Low re-bleeding rates in patients with negative findings Low re-bleeding rates in patients with negative findings of CE (5.6%–11%)of CE (5.6%–11%)

Complications Of Capsule Complications Of Capsule EndoscopyEndoscopy

Failure to enter the small bowelFailure to enter the small bowel Dyspahgia, GastroparesisDyspahgia, Gastroparesis Can insert endoscopicallyCan insert endoscopically

Failure to visualise all small bowelFailure to visualise all small bowel 10-16%10-16% DiabeticsDiabetics

Capsule RetentionCapsule Retention <1% for OGIB, up to 10% for Crohn’s disease<1% for OGIB, up to 10% for Crohn’s disease Caution with previous small bowel surgery or Caution with previous small bowel surgery or

abdominal radiotherapy or clinical suspicion of abdominal radiotherapy or clinical suspicion of obstructionobstruction

DBE or surgery to remove capsule +/- resect DBE or surgery to remove capsule +/- resect lesionlesion

What to do with the What to do with the ResultResult

NegativeNegative : Observe unless symptoms : Observe unless symptoms suggest further investigationsuggest further investigation

TumoursTumours : Consider resection : Consider resection UlcersUlcers : Stop aspirin/NSAIDs, consider : Stop aspirin/NSAIDs, consider

Crohn’s diseaseCrohn’s disease AngioectasiaAngioectasia : :

Reassurance and Iron Replacement (safest)Reassurance and Iron Replacement (safest) Assess antiplatelet agents or anticoagulantsAssess antiplatelet agents or anticoagulants If not controlled with iron, or intolerant of If not controlled with iron, or intolerant of

iron, then consider ablative therapyiron, then consider ablative therapy

Via Gastroscopy, Enteroscopy

or Colonoscopy

Patient Histology Capsule Endoscopy Quartile

Surgical Quartile

1 Carcinoid 4 4

2 Adenocarcinoma 4 4


4 Gastrointestinal Stromal Tumour

3 2


6 Cavernous Haemangioma

2 3

7 Lymphoma 1 1


3 2



2 1

11 Hyperplastic polyp 1 1

12 Cavernous Haemangioma

3 2

13 Ectopic Pancreas 3 2

Identical quartile in 7/13Different quartile by one in 6/13

324

105

58

104

57 57

1610 15

28

5 2 1 2

47

164

0

50

100

150

200

250

300

350

1 2 3 4

Quartile

Nu

mb

er

Angioectasia

Red Spot

Ulcer

Tumour

Anterograde Push Enteroscopy

Other indications for Small Other indications for Small Bowel Capsule EndoscopyBowel Capsule Endoscopy

Peutz-Jager syndromePeutz-Jager syndrome Crohn’s disease*Crohn’s disease* Coeliac disease*Coeliac disease* Abnormal SB radiology*Abnormal SB radiology*

* Not medicare rebateable* Not medicare rebateable

Other Types of CapsulesOther Types of Capsules

Patency CapsulePatency Capsule

Oesophageal CapsuleOesophageal Capsule

Colonic capsuleColonic capsule

So how do I get one?So how do I get one?

Refer for a consultationRefer for a consultation

OROR Fax information across and I can Fax information across and I can

have a lookhave a look

OROR Refer directly yourselfRefer directly yourself

Questions?Questions?

Documents

Capsule Endoscopy in Tamworth. True or False: “Capsule Endoscopy is a useful test in the diagnosis of unexplained anaemia” FALSE