Zvi Fireman

Men and postmenopausal women with iron deficiency anemia are routinely evaluated to exclude a gastrointestinal source of suspected internal bleeding. Iron deficiency anemia in premenopausal women is often treated with simple iron replacement under the assumption that the condition is due to excessive menstrual blood loss. To determine the yield of endoscopy evaluations in premenopausal women with iron deficiency anemia. Upper and lower gastrointestinal endoscopic examinations were conducted in 45 premenopausal women with iron deficiency anemia not related to gynecologic or nutritional causes. Forty-three of the 45 women fulfilled the entry criteria and were enrolled. Their mean age was 35 +/- 15 years and their mean hemoglobin level 9.3 +/- 2.3 g/dl. Twenty-eight upper gastrointestinal lesions were demonstrated in 24 of the 43 patients (55.8%): erosive gastritis in 12 (27.9%), erosive duodenitis in 4 (9.3%), erosive esophagitis in 3 (7.0%), hiatus hernia (with Cameron lesions) in 3 (7.0%), active duodenal ulcer in 1 (2.3%) and hyperplastic polyp (10 mm) in 1 (2.3%). Five lower gastrointestinal lesions were detected in 5 patients (16.3%): 2 (4.6%) had adenocarcinoma of the right colon, 2 (4.6%) had pedunculate adenomatous polyp > 10 mm, and 1 (2.3%) had segmental colitis (Crohn's disease). One patient (2.3%) had pathologic findings in both the upper and lower gastrointestinal tracts. Our findings of a gastrointestinal source of chronic blood loss in 28 of 43 premenopausal women with iron deficiency anemia (65.1%) suggest that this population will benefit from bi-directional endoscopic evaluation of the gastrointestinal tract.

Background/Aims: To compare the current differences with our earlier findings on the incidence and locations of colorectal cancer (CRC) among Israeli-born Jews and Arabs living within the same central coastal region in Israel. Methods: Data on demographics and the incidence and locations of malignancies were retrieved from hospital files of pathology-diagnosed patients with CRC throughout 1997–2003 and compared with equivalent data from 1988 to 1996. Results: Of the 624 patients recently diagnosed as having CRC, 562 (90.1%) were Jews and 62 (9.9%) were Arabs (p < 0.001). The average age of the entire cohort was significantly lower since our earlier study (72.9 ± 12.5 compared to 67.9 ± 12.7 years, p < 0.0001). The Jewish patients were significantly younger (p < 0.0001) but the Arab patients were not. The percentage of the adenocarcinoma being located in the right colon was significantly lower (p < 0.0006) and significantly higher in the rectum (p < 0.008). The reverse was true among the Jewish patients, but not significantly. Conclusions: Both study groups were younger than those in our earlier study. The lower incidence of CRC among the Arab patients persisted over time, but the location of their adenocarcinoma changed significantly. The increased incidence of CRC in ‘westernized’ countries is reflected in the Jewish but not the Arab community.

Capsule endoscopy: Improving transit time and image view

During ingestible capsule endoscopy, video images are recorded throughout the device's natural propulsion through the digestive system. Shortening the transit time of the wireless video capsule through the stomach and small bowel could reduce the time needed to read and analyze the resultant images, utilize more effectively the short life of the capsule battery (7 +/- 1 hours) and make it possible to image the entire small bowel. To measure gastric and small bowel transit times, with and without preparation, using capsule endoscopy. Capsule transit times through the stomach, small bowel and colon were evaluated by analysis of the videos generated during the capsule's passage. The study group included 62 patients with small and large bowel pathologies (e.g., iron deficiency anemia, Crohn's disease). The patients were divided into three groups: prepared with polyethylene glycol (Group A, n = 9), prepared with sodium phosphate (Group B, n = 13), and with no preparation (Group C, n = 40). The gastric emptying times were 20.4 +/- 15.2 minutes in group A, 55.7 +/- 45.1 in group B, and 48.3 +/- 28.7 in group C (P = 0.01). The capsule produced views of the cecum in only 49 of the 62 patients. The mean small bowel transit time for these 49 patients was 238.8 +/- 82.1 minutes, making the mean times for the groups (A,B,C) 148.9 +/- 32.6, 289.4 +/- 77.2 and 249.3 +/- 73.9 minutes respectively (P = 0.0001). Compared to both SP and no preparation, preparation of the colon with PEG significantly shortened the transit time of the capsule through the stomach and small bowel.

The Given Capsule procedure is a new system designed to aid the gastroenterologist in diagnosing small-bowel disease. Capsule endoscopy has provided gastroenterologists with easy access to small-bowel mucosa for examination by direct visualisation. The aim of our prospective study was to determine the indication for capsule endoscopy and to describe the identified pathology within the gastrointestinal tract. Patients with unexplained gastrointestinal bleeding from suspected small-bowel pathology of an undisclosed nature or with unexplained abdominal pain for more than 6 months were eligible to undergo capsule endoscopy. Patients with suspected intestinal obstruction or with a history of major abdominal surgery were excluded. One hundred and sixty patients (70 women, 90 men; mean age 49.0 +/- 19.8 years, range 13-91 years) ingested the capsule easily. They had undergone 6 +/- 2.9 investigative procedures before capsule endoscopy. Two (1.25%) patients who had non-natural excretions underwent surgery: one was found to have Meckel's diverticulum and the other had stricturing Crohn's disease. The mean haemoglobin in iron-deficiency anaemia patients was 9.1 +/- 2.2 g%. The diagnostic yield of capsule endoscopy was 57.7% in iron-deficiency anaemia and 52.4% in suspected Crohn's disease. Capsule endoscopy detected the more clinically significant intestinal lesions. It was of diagnostic value in patients with obscure bleeding, suspected Crohn's disease and malabsorption, but the diagnostic yield in patients with chronic pain or irritable bowel syndrome-type symptoms was low.

Objectives:Chronic occult blood loss from the gastrointestinal tract is a recognized major cause of iron-deficiency anemia. After conventional investigation of the upper and lower parts of the gastrointestinal tract, the source of bleeding remains unidentified in ~10% of these patients. We evaluated the diagnostic yield of capsule endoscopy from patients enrolled in clinical studies due to persistent or recurrent iron-deficiency anemia. Methods: In this large cohort study, patients with obscure gastrointestinal bleeding were identified in a company-sponsored clinical study (Given Imaging, Ltd.) database which contains data from >50 clinical studies. Information on suitable patients was derived from 31 of them. Each subject swallowed an M2A® Given Capsule containing a miniature video camera, batteries, a transmitter and an antenna. Recording time was ~8 h. The capsule was excreted naturally in the patient’s bowel movement, and the data it transmitted were retrieved and interpreted the next day. Results: 293 patients were studied (135 males, 46.1%, mean age 59.4 ± 16.8 years) whose mean number of bleeding episodes was 4.3 ± 5.5 and mean hemoglobin level was 9.8 ± 2.4 g/dl. The average number of diagnostic procedures per patient prior to the capsule endoscopy study was 5.59. Capsule endoscopy detected definitive findings in 213/293 patients (72%) and findings missed by other diagnostic procedures in 22/293 patients (8%). Neither capsule endoscopy nor the other diagnostic procedures yielded diagnoses in 58/293 patients (20%). Conclusions: Capsule endoscopy has a high diagnostic yield in evaluating patients with obscure gastrointestinal bleeding.

Background: The small bowel is the most commonly affected site of Crohn’s disease (CD) although it may involve any part of the gastrointestinal tract. The current methodologies for examining the small bowel are x ray and endoscopy. Aims: To evaluate, for the first time, the effectiveness of wireless capsule endoscopy in patients with suspected CD of the small bowel undetected by conventional modalities, and to determine the diagnostic yield of the M2A Given Capsule. Patients: Seventeen patients (eight males, mean age 40 (15) years) with suspected CD fulfilled study entry criteria: nine had iron deficiency anaemia (mean haemoglobin 10.5 (SD 1.8) g%), eight had abdominal pain, seven had diarrhoea, and three had weight loss. Small bowel x ray and upper and lower gastrointestinal endoscopic findings were normal. Mean duration of symptoms before diagnosis was 6.3 (SD 2.2) years. Methods: Each subject swallowed an M2A Given Capsule containing a miniature video camera, batteries, a transmitter, and an antenna. Recording time was approximately eight hours. The capsule was excreted naturally in the patient’s bowel movement, and the data it contained were retrieved and interpreted the next day. Results: Of the 17 study participants, 12 (70.6%, six males, mean age 34.5 (12) years) were diagnosed as having CD of the small bowel according to the findings of the M2A Given Capsule. Conclusions: Wireless capsule endoscopy diagnosed CD of the small bowel (diagnostic yield of 71%). It was demonstrated as being an effective modality for diagnosing patients with suspected CD undetected by conventional diagnostic methodologies.