capsule experience - MG Lorenzatto

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Chapter 5 Neoplastic Diseases Francesco P. Rossini, M.D. Marco Pennazio, M.D. INTRODUCTION Tumors of the small bowel comprise 5% to 7% of all gastrointestinal tumors. With the use of more accurate diagnostic methods, diagnosis of small bowel tumors has become more frequent and it is probable that the actual incidence is underestimated. The most important symptom in cases of small bowel neoplasia is undoubtedly obscure bleeding with secondary iron deficiency anemia. Indeed, small bowel tumors are the second most common cause of obscure gastrointestinal bleeding, accounting for 5% to 10% of all cases of chronic blood loss. Among patients with obscure gastrointestinal bleeding, small bowel tumors are the single most common lesion in patients below 50 years of age. Having excluded the upper and lower portions of the gastrointestinal tract, attention should be concentrated on the small bowel as being responsible for bleeding. This strategy probably affords the rapid identification of a tumor as a cause of the bleeding. The most frequent location both for epithelial tumors and for non-epithelial small bowel tumors is the jejunum rather than the ileum. Adenomas, adenocarcinomas, and gastrointestinal stromal tumors (GISTs) are much more frequent in the duodenum and jejunum. Metastatic tumors may occur in different parts of the small bowel and carcinoids are more common in the ileum. Adenomas are the most common benign small bowel tumors with malignant potential and adenocarcinoma is the most common malignant small bowel tumor. Carcinoid tumors are the second most frequent neoplasm encountered in the small bowel. Primary intestinal lymphoma accounts for about 20 to 30% of malignant neoplasms of the small bowel and is the third most common small bowel neoplasm. Among vascular tumors, hemangiomas and lymphangiomas account for 3% to 8% of all benign small bowel neoplasms; Kaposi's sarcoma is the most frequent neoplasm in AIDS patients. GISTs are non-epithelial neoplasms that originate from cells located in the wall of the stomach and small bowel and are characterized by extreme variability of differentiaton potential. GISTs with smooth muscle differentiation (leiomyomas) are the secondcommonest benign tumors of the small bowel. GISTs with neural differentiation (schwannomas, gastrointestinal autonomic nerve tumors) are rare neoplasms that may be the cause of obscure gastrointestinal bleeding. CAPSULE EXPERIENCE Diagnostic methods for small bowel tumors include enteroclysis, CT, MR imaging, arteriography, enteroscopy and capsule endoscopy. Barium studies of the small bowel have low diagnostic yield. In our personal experience of 24 patients 47
48 Chapter 5 with small bowel tumors identified enteroscopically, only 25% had enteroclysis compatible with the presence of a small bowel tumor. Although tumors may escape diagnosis even with enteroscopy, in any case it appears to be superior to barium studies of the small bowel in patients with obscure bleeding in whom tumor is suspected. The two methods are usually considered to be complementary, but it is hoped that recently introduced diagnostic methods such as helical CT enteroclysis, MR enteroclysis and, above all, capsule endoscopy may modify the non invasive diagnostic approach to this important pathology. In the two clinical trials performed in the United States and in Italy to evaluate the use of capsule endoscopy in patients with obscure bleeding reported so far, 2 out of 36 patients (5%) were ultimately diagnosed to have a small bowel tumor and had curative surgery. This further stresses that capsule endoscopy is an extremely promising tool for the diagnosis of small bowel tumors. Capsule endoscopy and push enteroscopy are also extremely important in the surveillance of groups of patients with increased risk of small bowel tumors, such as the following precancerous conditions: celiac disease, ulcerative jejunoileitis, familial adenomatous polyposis (FAP), Peutz-Jeghers syndrome (PJS), juvenile polyposis, immunodeficiency syndromes, alpha-chain disease, small bowel adenomas, hereditary non-polyposis colorectal cancer syndrome (HNPCC). In particular, in patients with FAP or PJS, whereas surveillance of the upper and lower gastrointestinal tract is easily achieved through esophagogastroduodenoscopy and total colonoscopy with terminal ileoscopy, the small bowel is still an important and challenging problem. Capsule endoscopy offers the great opportunity to identify polyps and map their distribution. It is to be hoped that this new technique will be able to replace Neoplastic Diseases the more invasive enteroclysis in the surveillance strategy for the small bowel. A follow-up program might be based on periodic capsule endoscopies, and the use of other techniques such as push enteroscopy and/or intraoperative enteroscopy could be targeted on the basis of the data acquired by the capsule. CONCLUSION Capsule endoscopy is highly innovative both from the technological and the clinical standpoint, since it provides non invasive visualization of areas of the small bowel that are not easily accessible using wired endoscopy. There is also the undoubted advantage of a simple, complication-free procedure that does not require hospitalization. Capsule endoscopy opens up new horizons for the diagnosis of small bowel tumors. It will very probably bring about the progressive abandonment of some currently used invasive and costly diagnostic methodologies (which also have a low diagnostic yield), which greatly increase the cost of managing gastroenterological patients. References and Suggested Readings 1 Rossini FP, Risio M, Pennazio M. Small bowel tumors and polyposis syndromes. Gastrointest Endosc Clin N Am 1999; 9: 93-114 2 Lewis BS, Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: the results of the first clinical trial. Gastrointest Endosc 2001; 53: 70 3 Pennazio M, Santucci R, Rondonotti E, et al. Wireless capsule endoscopy in patients with obscure gastrointestinal bleeding: preliminary results of the Italian multicentre experience. Digest Liver Dis 2001; 33: 2 4 Pennazio M, Rossini FP. Small bowel polyps in Peutz-Jeghers syndrome: management by combined push enteroscopy and intraoperative enteroscopy. Gastrointest Endosc 2000; 51: 304-8 5 Rossini FP, Pennazio M. Small bowel endoscopy. Endoscopy 2002; 34:13-20
Page 1 and 2: Atlas of Capsule Endoscopy Editors:
Page 3 and 4: Atlas of Capsule Endoscopy Marisa H
Page 5 and 6: Acknowledgments We would like to th
Page 7 and 8: Table of contents Development of th
Page 9 and 10: 4 Development of the Swallowable Vi
Page 11 and 12: Notes From the Inventor Gavriel J.
Page 13 and 14: 10 Chapter 1 THE OPTICAL DOME The o
Page 15 and 16: 12 Chapter 1 c. Conscious sedation
Page 17 and 18: 16 Chapter 2 Typical timing of a ca
Page 19 and 20: 18 Chapter 2 Figure 1. Intializing
Page 21 and 22: 20 Chapter 2 Figure 5. Time Capsule
Page 23 and 24: 24 Chapter 3 becomes very obvious.
Page 25 and 26: 26 Chapter 3 M2A ® M2A ® Figure 3
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Page 75 and 76: Chapter 8 Malabsorption Gerard Gay,
Page 77 and 78: Chapter 8 References and Suggested
Page 79 and 80: Chapter 8 Endoscopic management of
Page 81 and 82: Chapter 8 M2A ® M2A ® Figure 8.1e
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104 Chapter 9 Our preliminary data
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106 Chapter 9 M2A ® M2A ® Figure
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108 Chapter 9 M2A ® Figure 9.4a 11
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112 Chapter 10 transplant. Indicati
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116 Chapter 10 M2A ® Figure 10.4c
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120 Chapter 11 CONCLUSION During th
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122 Chapter 11 M2A ® Figure 11.4a
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Contributors Carla Abbiati, M.D. Un
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128 Contributors (continued) Sandor
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130 Contributors (continued) Ana Sa
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capsule experience - MG Lorenzatto

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