Outcome of Capsule Endoscopy in Determining Indication and Route for Push-and-Pull Enteroscopy

Background and Study Aim: Video capsule endoscopy and push-and-pull enteroscopy (PPE), both allow a complete examination of the small bowel in patients with suspected intestinal disorders. Due to the invasiveness of PPE, indications should probably be selective. The aim of the present prospective study was to evaluate the outcome of an approach whereby capsule endoscopy was used to select patients in whom PPE was indicated.
Patients and Methods: 164 patients were included (90 men; age 54 ± 18 years) with various indications for small-bowel investigation, such as obscure bleeding (n = 88), suspected Crohn’s (n = 14) or celiac (n = 12) disease, or known or strongly suspected localized diseases such as neoplasms (n = 18) for biopsy. Four patients with a suspected intestinal stenosis underwent PPE without prior capsule endoscopy. In the remaining 160 patients, who had a capsule endoscopy, PPE was selected if there were lesions requiring biopsy or angiodysplasias to be treated by argon plasma coagulation (APC). Regarding the insertion route, an anal PPE was indicated if the capsule transit time from ingestion to arrival at the lesion was ≥ 75 % of the total time from ingestion to arrival at the cecum. After gut cleansing, PPE was performed with general anesthesia, and the small bowel was examined until the lesion was reached or the scope could not be advanced further. If the suspected lesion had not been reached, a second procedure was performed through the alternative route, under the same conditions.
Results: The diagnostic yield of capsule endoscopy was 75 %. According to the indications, 47 PPE procedures were performed in 42 patients, including 33 through the oral route, 4 through the anal route and 5 combined ones. Indications were: suspicion of intestinal tumor (n = 13), celiac disease with chronic bleeding (n = 4), suspicion of Crohn’s disease (n = 3), treatment of significant arteriovenous malformations (AVMs) (n = 10), diffuse enteropathies (n = 3), nonsteroidal anti-inflammatory drug (NSAID)-related conditions (n = 2), and obscure digestive bleeding (n = 3). Lesions detected by capsule endoscopy were reached by PPE in all but two cases. The positive predictive value (PPV) of capsule endoscopy to make a correct indication for PPE was 94.7 % and the negative predictive value (NPV) was 98.3 %. The PPV and NPV of a time index of > 0.75 to start via the anal route were 94.7 % and 96.7 %. No complications were observed and all patients were discharged the day after the procedure. Follow-up at 9 months showed that capsule endoscopy followed by PPE had positively influenced the management of 90.5 % of the patients.
Conclusions: The use of capsule endoscopy as a filter for PPE results in effective management of patients with various intestinal diseases. Capsule endoscopy can also direct the choice of route of PPE; a time index of > 0.75 appears to reliably indicate an anal route so that a double procedure is required in only about 12 % of cases.

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