Marco Pennazio

Research interest in small-bowel endoscopy continues to be strong, even though 5 years have now passed since the advent of capsule endoscopy (CE), followed by that of double-balloon endoscopy (DBE), causing a revolution in this sector of endoscopy. Fully 120 scientific contributions on the subject were presented at Digestive Disease Week (DDW) this year, 83 of which concerned CE, 27 DBE, with 10 being comparisons between the two techniques (Figure [ 1 ]). This review discusses in detail the 20 most significant of these. Numerous studies have analyzed technical aspects of CE and the wide therapeutic applications of DBE, often in series that were insufficiently large, heterogeneous, and mainly with retrospective analysis. Gastrointestinal bleeding is still the field in which the two methods are most often clinically applied, and that in which the scientific evidence is most solid. For some indications for CE, such as inflammatory bowel diseases and esophageal disorders, there is still controversy regarding its real clinical usefulness. Most comparative studies hold that CE is a valuable screening test, while DBE should serve as the confirmatory/therapeutic modality (Figure [ 2 ]). Figure 1 Number of abstracts devoted to capsule endoscopy (CE) and to double-balloon endoscopy (DBE) at DDW 2006. Figure 2 a Capsule endoscopy (CE): a large angiectasia in the mid-ileum of a patient with obscure-overt bleeding. b Double-balloon endoscopy: the same patient, showing the lesion previously identified by CE. c Double-balloon endoscopy: ileal angiectasia after argon plasma cauterization.

This is the fourth contribution to appear in this Picture Gallery series dealing with small-intestinal pathology as seen at capsule endoscopy. These articles are appearing consecutively in the eighth to the eleventh issues of Endoscopy.

This year’s Digestive Disease Week saw the presentation of more than 80 studies focusing on capsule endoscopy (CE); this review discusses in detail the 20 most significant of these. Alongside various reports concerning technical aspects of the procedure, possible new applications have been studied, including in celiac disease. Obscure bleeding is now a consolidated indication to CE; however, prospective data on the impact of CE on clinical outcomes are still scarce. Opinions diverge on the effective role of CE in Crohn’s disease, and further research is needed to define this role. Research is also underway to develop capsules with propulsive and therapeutic capabilities. The strong interest in small-bowel endoscopy is also shown by the numerous studies concerning double-balloon enteroscopy, a complementary procedure to CE (Figure [ 1 ]). Figure 1 The numbers of abstracts devoted to capsule endoscopy and double-balloon enteroscopy at Digestive Disease Week 2005.

The annual incidence of gastrointestinal bleeding in the United States has been conservatively estimated at approximately 100 episodes per 100,000 persons, accounting for approximately 300,000 hospitalizations per year [ 1 ]. Obscure gastrointestinal bleeding represents about 5 % of those patients with gastrointestinal bleeding of any type. It is defined as bleeding of unknown origin that persists or recurs (i. e., recurrent or persistent iron-deficiency anemia, fecal occult blood test positivity, or visible bleeding) after a negative initial or primary endoscopy (upper and/or lower gastrointestinal endoscopy) [ 2 ]. The source of bleeding is frequently located in the small bowel and can result from a number of conditions, including vascular lesions, tumors, and inflammatory lesions. Radiographic techniques for evaluation of the small bowel are relatively insensitive for flat, small, infiltrative, or inflammatory bleeding lesions. Other imaging techniques such as angiography and radioisotope bleeding scan are insensitive in the absence of brisk bleeding. Intraoperative enteroscopy is the most complete but also the most invasive means of examining the small bowel. Push enteroscopy is at present considered an effective diagnostic procedure, but it is time-consuming and only allows exploration of the jejunum [ 3 ]. Double-balloon enteroscopy is a new specialized method for enteroscopy. Outcomes have been promising for achieving complete enteroscopy and providing therapy without the need for laparotomy [ 4 ], but the use of this method is still not widespread. Capsule endoscopy (CE) is a valuable tool in the diagnostic toolkit. Key advantages of CE include: ability to review and share images; patient preference; safety profile; ability to conduct the procedure in a variety of settings; clarity of image, comparable to other forms of endoscopy; and ability to image the entire small bowel. This paper reviews the data reported in the scientific literature concerning the influence of CE in the management of patients with gastrointestinal bleeding and its potential impact on health outcomes.

This is the third of four articles dealing with pathology of the small intestine as seen at capsule endoscopy. These contributions are appearing consecutively in the eighth to the eleventh issues of Endoscopy.

Capsule endoscopy is a major breakthrough in gastrointestinal endoscopy and is a first-line tool to detect abnormalities of the small bowel, in up to 50% of patients, intestinal disorders are not associated with any physical findings or positive tests. Indications, yield and impact on patient management of this method of diagnosing small-bowel diseases are analyzed critically in light of current scientific knowledge.

This is the second of four articles dealing with small-intestinal pathology as seen at capsule endoscopy. These contributions will appear from the eighth to the eleventh issues consecutively.