Introduction

Colon capsule endoscopy (CCE) has been demonstrated to be comparable to colonoscopy and better than CT colonography (CTC) for the detection of colonic pathology. Challenges include poor completion rates and high re-investigation rates.

Aims & Methods

The aim of this study was to assess the role of CCE with faecal immunochemical testing (FIT) as a non-invasive, diagnostic tool in symptomatic and screening populations attending Connolly Hospital.
Prospective participants were identified from both the central endoscopy waiting list at Connolly Hospital and from our national colorectal screening programme, Bowel Screen. All participants were due to attend Connolly Hospital for a symptomatic or surveillance colonoscopy during the time period of the study. Consenting participants underwent CCE the day prior to their scheduled colonoscopy. CCEs were read by two expert readers. Participants were sent FIT kits to complete prior to CCE. Primary outcomes were CCE polyp detection rates (PDR). The potential benefit of using FIT as a triage tool to identify low-risk individuals appropriate for CCE over colonoscopy was explored.

Results

80 back-to-back procedures were completed January 2023-February 2024 (M: F 50:30, mean age 59.6, range 35-78) in a single centre. The most common indications for colonoscopy were surveillance 41.5%, PR bleeding 21% and diarrhoea/ IBD assessment 15%.
CCE detected a total of 108 polyps in 45/80 (56%) participants versus 93 polyps in 39/80 (48%) participants at colonoscopy (p= 0.34). When only complete CCE are included, the polyp detection rate increased to 31/45 (68%), p< 0.05. 79% supplied FITs prior to CCE. CCE PDR for all polyps when FIT < 50 ng/ml was 19/33 (57%) versus (20/27) 74% with FIT > 50 ng/ml (p=0.18). There is trend towards significance. A lower FIT cut-off, closer to limit of detection, not available to this study, may have more significant results.
Only one participant had a cancer diagnosed at colonoscopy. It was located on the ileocaecal valve. The cancer was not detected by CCE despite the capsule passing through this region. This, to our knowledge, is only the second missed cancer by CCE documented.
ESGE 2012 guidelines recommend follow up colonoscopy for one polyp measuring 6mm or more, or if three polyps of any size are detected. 50/80 (62.5%) CCE examinations would have required follow up if they were not part of a study and scheduled for next day colonoscopy. Even when looking at only those CCE examinations that were complete, 17/45 (38%) required further investigation. Reasons for re-investigation included incomplete examination 32/49 (65%), for polypectomy 16/49 (33%) and for biopsy in 1/49 (2%).
False negative CCE rates for polyps greater than 6mm range from 2-15.5% in the literature. In keeping with this, the false negative CCE for all polyps in this study was 8.75%, and 6.25% for polyps greater than 6mm.
There were no adverse events reported. There were technical issues reported in 16% of CCE. These included the capsule not turning on until it was beyond the caecum, participants removing the belt intermittently and one interference which was believed to be secondary to a topical glucose monitor.

Conclusion

The increasing demand on colonoscopy waiting lists raises concerns regarding the ability of health services to deliver traditional endoscopy in a timely fashion. Alternative modalities are necessary and CCE is a viable diagnostic alternative. There is likely a role for FIT testing as a triage tool prior to CCE to reduce re-investigation rates.

Introduction

A patency capsule (PC) test is advised before video capsule endoscopy (VCE) to prevent capsule retention in high-risk patients. Although up to 30% of patients cannot expel the PC within 30 hours and are ineligible for VCE, those without strictures, but with slow transit time, can safely undergo VCE. Currently there are no recommendations regarding PC protocol.

Aims & Methods

In this prospective cohort study, we aimed to evaluate the success rate of a 2^nd PC attempt with augmented pro-motility preparation protocol, in patients who previously failed to pass PC and to ascertain the risk factors for failure in PC test.

During 2019-2023, Patients who failed their initial PC test in our referral center were offered to undergo a 2^nd augmented pro-motility bowel preparation protocol (Table 1). Exclusion criteria: age<18 years, total colectomy or ileostomy and inability to sign informed consent. Patients were followed during the 2^nd PC test and the subsequent VCE for success rates and safety outcomes, i.e. VCE retention. Demographic and clinical characteristics were collected for assessing potential risk factors for 1^st PC failure and successful 2^nd PC by multivariate regression analysis.

Results

A total of 396 patients performed a PC test and were included in the study (age 45.4±18.6 years, male gender 47.7%). The indications for VCE were suspected/established Crohn's disease (86.1%); anemia/bleeding (8.3%) and radiologic findings (5.6%). Successful PC expulsion was documented in 323 (81.6%) patients, while 73 (18.4%) failed. A 2^nd attempt with augmented pro-motility protocol was accepted by 35/73 patients (48%) and rejected by 38/73 patients (52%). no clinico-demographic differences between the groups. Successful 2^nd PC attempt was documented in 20/35 patients (57%), with all of them completing VCE without adverse events. Failed 2^nd PC was documented in 15/35 patients (43%) without adverse events, while 3/15 performed tandem abdominal CT confirming PC in colon (i.e false failure) followed by uneventful VCE.

Performance of a 2^nd PC attempt reduced the failed PC rate by 57% (Absolute risk reduction) and the number needed to treat (NNT) is 1.8 for a successful 2^nd attempt. Multivariate regression for success with 2^nd PC vs. 1^st PC was limited by small numbers. However, diabetes mellitus showed a trend as a risk factor (9.6% in 1^st PC test success vs. 20% in 2^nd PC test success, OR 3.7, p=0.057, adjusted for age, gender, BMI and stools/day).

Conclusion

In this prospective cohort study, a novel augmented pro-motility PC test preparation protocol improved the success rate in patients who previously failed an initial PC test, without any adverse events. Subsequent abdominal CT should be considered in selected cases to further reduce false positive results. Patients with diabetes mellitus might benefit from performing the augmented protocol upfront, but further large-scale studies are required to establish that.

Table 1: Patency Capsule Preparation Protocols

Disclosure

Nothing to disclose

Introduction

Video capsule endoscopy(VCE) is an useful and safe examination in diagnosis of small bowel disease. VCE is composed of one wide-view front lens, flashlight and 8 hour battery to take small bowel images.. In early models, the relative short battery time lead to a modest completion rate about 83.5% in meta-analysis. The battery time of new generation VCE increased to at least 12 hour and even up to 18 hours in real-world practice which made extended examination possible. The effect of prolonged VCE examination time on VCE performance was less explored.

Aims & Methods

This study is aimed to evaluate the completeness and diagnostic yield in patients receiving prolonged VCE examinations. From year 2016 we started to perform an overnight protocol for VCE examination in our hospital using Olympus endocapsule 10, EC-10; Olympus Corp., Japan). After 10 ml simethicone ingestion, the patient swallowed the capsule endoscope. The doctors checked the capsule endoscopy 2-3 hours after capsule endoscope for confirmation of small bowel entering. The patient kept capsule endoscope recording overnight until the coming morning when patients came back to clinic. For some inpatients with active bleeding, VCE was checked at least after 12 hours at midnight. The VCE recording was stopped earlier if colon arrival is confirmed. All the CE procedures were read by experienced endoscopist. We reviewed consecutive VCE examination records from Jan 2016 to Dec 2020. VCE Completeness was defined as the capsule endoscopy reached the cecum within recording time. We subcategorized the VCE records into within 8 hours, within 12 hours and whole procedure and compared VCE complete rate and diagnostic yield between groups. The Cochran’s Q test was used for statistical analysis. P values less than .05 were considered significant.

Results

Total 88 patients aged 20-90 years old received VCE in the study period. Their median age was 69 years old and 46 patients(52.3%) were male. 69 patients(78.4%) were inpatient and 84 patients(95%) were suspected with small bowel bleeding. The small bowel transit time was 342 minutes(91-1134minutes) with total exam time measuring 1031 minutes (452 to 1273 minutes). 58% of patients completed small bowel evaluation within 8 hours since capsule endoscope ingestion, significantly lower than 79.5% within 12 hours(p<0.001), and 93.2 %(p<0.001) in whole course overnight study. The diagnostic yield was 71.6% within 8 hours, also significantly lower than 81.8% within 12 hours(p<0.001) and 83% in whole course overnight study(<0.001%).(Table) No capsule retention was encountered in this study.

Conclusion

1. Prolonged overnight VCE examination can improve complete rate and diagnostic yield using capsule endoscope whose battery life over 12 hours. 2. Prolonged overnight VCE examination should be considered to be routine practice, especially for inpatients.

Disclosure

None

Introduction

Non-alcoholic fatty liver disease (NAFLD) is a common liver condition, and liver biopsy is considered the gold standard to diagnose and stage the disease [1]. However, the risks associated with the invasive procedure limit its widespread use, making noninvasive methods for assessing the severity and progression of fibrosis essential in pediatric NAFLD cohorts [2].

Aims & Methods

To investigate the levels of transforming growth factor-beta 1 (TGF-β1) and glycosaminoglycans (GAGs) in obese children with NAFLD and assess their diagnostic accuracy.
94 children aged 9 to 17 years (average age 12.15 ± 2.51 years) were examined. According to the transient elastography data (FibroScan®502touch, Echosence, France) and body mass index, children were divided into four groups:1 group - 27 obese NAFLD children with fibrosis ≥F1, group 2 - 35 obese NAFLD children without fibrosis, group 3 - 18 obese children without NAFLD and fibrosis. Group 4 (control) comprised 14 children with normal weight without NAFLD and liver fibrosis. Serum transforming growth factor-beta 1 (TGF-β1) levels were evaluated by enzyme-linked immunosorbent assay (ELISA) using the IBL International (Germany) test system, and glycosaminoglycans (GAG) levels were determined spectrophotometrically. ROC analysis was performed for cut-off values calculation.

Results

The highest level of TGF-β1 was found in 1 group children –up to 153.4 (99.7; 189.1) pg/ml, which was significantly higher than in 2 group- 72.4 (53.1; 111.3) pg/ml (p˂0,05), 3 group - 74.0 (50.6; 99.4) pg/ml (p˂0,05) and 4 group - 56.1 (46.0; 77.4) pg/ml (p˂0,05). Moreover, 1 group of children demonstrated increased GAG content up to 4.50 (3.21; 4.60) mmol/L (p˂0,05). ROC analysis revealed that cut-off serum TGF-β1 96.8 pg/ml predicted liver fibrosis in NAFLD children. The area under the curve (AUROC) was 0.787 (p<0.001), the sensitivity of the test was 80.0%, and the specificity was 65.7%. The threshold GAG value for fibrosis was 4.24 mmol/L (sensitivity 70.6%, specificity 69.6%, AUROC 0.743 (p<0.01)).

Conclusion

TGF-β1 and GAG are reliable noninvasive fibrosis markers in children with NAFLD, allowing for their use in liver fibrosis screening.

References

1. Gawrieh S, Harlow KE, Pike F, et al. Relationship of Enhanced Liver Fibrosis Score with Pediatric Nonalcoholic Fatty Liver Disease Histology and Response to Vitamin E or Metformin. J Pediatr. 2021;239:161-167.e5. doi:10.1016/j.jpeds.2021.08.012.
2. Draijer L, Benninga M, Koot B. Pediatric NAFLD: an overview and recent developments in diagnostics and treatment. Expert Rev Gastroenterol Hepatol. 2019;13(5):447-461. doi:10.1080/17474124.2019.1595589

Clinical Case Summary

A 34 year old female attended electively for liver biopsy for investigation of deranged liver function tests (LFTs).
Ultrasound guided percutaneous liver biospy was complicated by immediate abdominal pain with computed tomography (CT) abdomen revealing right subphrenic intracapsular fluid contained within the liver capsule in keeping with post biopsy haemorrhage. This was managed conservatively with overnight admission for observation.
The patient represented within 48h hours with worsening jaundice and severe abdominal pain. LFTs had significantly worsened with a hyperbilirubinaemia of 153 umol/L with a cholestatic pattern. Repeat CT abdomen showed new intrahepatic and extrahepatic bile duct dilation with common bile duct (CBD) measuring up to 16 mm in diameter. In the lower CBD, there was an obstructing opacity measuring approximately 7 mm in diameters by 24 mm longitudinal and given the clinical history, a blood clot was to be the most felt likely be the underlying aetiology.
Urgent endoscopic retrograde cholangiopancreatography (ERCP) was performed. An initial cholangiogram revealed a dilated biliary system with ill-defined opacity distally. Following sphincterotomy a large clot was extracted with a 12 millimetre balloon. Final cholangiogram showed clearance of bile ducts with no post procedural complications. The next day updated imaging with CT abdomen showed complete resolution of the biliary duct dilatation and LFTs had improved to pre-liver biopsy baseline. The patient was discharged with no further complications.
Discussion: Haemobilia is recognised as a rare complication from percutaneous liver biopsy with incidence rate of less than 1% (1). The management of haemobilia may be conservative in minor cases with transcatheter arterial embolization usually recommended as first line intervention and ERCP used for biliary drainage (2). In this case we demonstrated a successful outcome in biliary decompression following clot extraction with ERCP.

References

(1) Thomaides-Brears, H.B., Alkhouri, N., Allende, D. et al. Incidence of Complications from Percutaneous Biopsy in Chronic Liver Disease: A Systematic Review and Meta-Analysis. Dig Dis Sci 67, 3366–3394 (2022).
(2) Yilmaz N: Hemobilia Causing Acute Cholecystitis and Pancreatitis after Percutaneous Liver Biopsy: A Case Report and Review of the Literature. Visc Med 2020;36:246-250.