Endoscopy

Question 1

Capsule Endoscopy

Answer 1

Capsule endoscopy

Capsule endoscopy is currently used in UK to identify the source of occult gastrointestinal bleeding when an OGD and colonoscopy and failed to show a cause. It is particularly useful for identifying pathology in the ileum.

Question 2

Capsule Endoscopy - Example Question

Answer 2

A 55-year-old lady if referred to the gastroenterology clinic. She has a 3-year history of iron deficient anaemia despite iron therapy. When you see her she describes feeling tired all of the time with no energy. She denies any haematemesis, weight loss, melena or fresh red blood PR. She also denies any haemoptysis, cough or urinary symptoms. She is post-menopausal and has not been on any HRT. She is a non-smoker and drinks alcohol socially. She is otherwise well and only on Ferrous sulphate 200mg BD. On examination, she has pale conjunctiva but an examination is otherwise unremarkable. She has been admitted twice over the last 6 months for blood transfusions and has subsequently dropped her Hb after being discharged.

She has been extensively investigated by her GP who has attached her test results with the referral letter.

Hb 81 g/l
MCV 69 fl
Platelets 299 * 109/l
WBC 6.2 * 109/l

Na+	141 mmol/l
K+	4.1 mmol/l
Urea	7.1 mmol/l
Creatinine	101 µmol/l
CRP	11 mg/l

Bilirubin 10 µmol/l
ALP 56 u/l
ALT 21 u/l
Albumin 38 g/l

Serum electrophoresis no paraprotein
Immunoglobulins within normal limits
Ferritin 4 ng/mL (10-150)

USS abdomen: NAD
Transvaginal USS: NAD
CT chest, abdomen and pelvis: NAD
OGD: NAD
Colonoscopy: NAD

Faecal occult blood: positive

The Gastroenterologist that sees her suspects an occult GI bleed. What is the next most appropriate investigation for this lady?

	Endoscopic ultrasound
	CT angiography
	Repeat colonoscopy
	> Capsule endoscopy
	Repeat CT chest abdo and pelvis

This lady has an occult GI bleed. The SIGN guidelines for occult bleeding recommend OGD and colonoscopy. If they are both normal they recommend either repeat OGD or capsule endoscopy. If the capsule is negative then either a second capsule or enteroscopy is indicated. CT angiography would be used for acute occult bleeding where the patient is compromised and embolisation of the bleeding vessel is needed.

Question 3

Angiodysplasia and Capsule Endoscopy: Example Question

Answer 3

A 65-year-old woman comes to the gastroenterology clinic with persistent iron deficiency anaemia. she has had two colonoscopies and one upper GI endoscopy without finding a significant lesion, and haemoglobin continues to drop despite iron replacement. On examination she has a blood pressure of 142/105 mmHg, her pulse is 75 and regular. She looks pale. You note an ejection systolic murmur. Which of the following is the most appropriate way to investigate her?

	> Capsule endoscopy
	CT colonoscopy
	Labelled white cell scan
	Repeat upper GI endoscopy
	Repeat colonoscopy

The suspicion here is a diagnosis of Heyde’s syndrome, with aortic stenosis and small bowel angiodysplasia. The pathogenesis of the angiodysplasia is unknown but may be related to local circulatory changes because of the valve stenosis. Further conventional endoscopy is not likely to be useful, capsule endoscopy that can adequately visualise the small bowel. Angiodysplasia usually resolves once the valve is repaired.

Further conventional endoscopy investigations have potentially a less than 5% chance of picking up a previously undetected lesion. Labelled white cell scan is most useful for large volume bleeding, and CT colonoscopy is less sensitive than conventional endoscopy.

Question 4

Occult GI Bleed

Answer 4

The SIGN guidelines for occult bleeding recommend OGD and colonoscopy.

If they are both normal they recommend either repeat OGD or capsule endoscopy.

If the capsule is negative then either a second capsule or enteroscopy is indicated.

CT angiography would be used for acute occult bleeding where the patient is compromised and embolisation of the bleeding vessel is needed.

Question 5

Heyde’s Syndrome

Answer 5

Hyde’s syndrome = aortic stenosis and small bowel angiodysplasia.

The pathogenesis of the angiodysplasia is unknown but may be related to local circulatory changes because of the valve stenosis.

Conventional endoscopy is not likely to be useful,
Ix = Capsule endoscopy that can adequately visualise the small bowel. Angiodysplasia usually resolves once the valve is repaired.

NB: Further conventional endoscopy investigations have potentially a less than 5% chance of picking up a previously undetected lesion.