Diagnostic yield of esophagogastroduodenoscopy, colonoscopy, and small bowel endoscopy in Thai adults with chronic diarrhea

Background Gastrointestinal endoscopy is frequently recommended for chronic diarrhea assessment in Western countries, but its benefit in the Southeast Asia region is not well established. Methods Medical records of consecutive patients undergoing esophagogastroduodenoscopy (EGD), colonoscopy, and small bowel endoscopy for chronic diarrhea from 2008 to 2018 were reviewed. Small bowel endoscopy included push enteroscopy, balloon-assisted enteroscopy (BAE), and video capsule endoscopy (VCE). The diagnostic yield of each endoscopic modality and predictors for positive small bowel endoscopy were analyzed. Results A total of 550 patients were included. The mean age was 54 years, and 266 (46.3%) patients were male. The mean hemoglobin and albumin levels were 11.6 g/dL and 3.6 g/dL, respectively. EGD and colonoscopy were performed in 302 and 547 patients, respectively, and the diagnostic yield was 24/302 (7.9%) for EGD and 219/547 (40.0%) for colonoscopy. EGD did not reveal positive findings in any patients with normal colonoscopy. Fifty-one patients with normal EGD and colonoscopy underwent small bowel endoscopy. Push enteroscopy, BAE, and VCE were performed in 28, 21, and 19 patients with a diagnostic yield of 5/28 (17.9%), 14/21 (66.7%), and 8/19 (42.1%), respectively. Significant weight loss, edema, and hypoalbuminemia were independent predictors for the positive yield of small bowel endoscopy. Conclusion Colonoscopy was an essential diagnostic tool in identifying the cause of chronic diarrhea in Thai patients, whereas EGD provided some benefits. Small bowel endoscopy should be performed when colonoscopy and EGD were negative, particularly in patients with significant weight loss, edema, and hypoalbuminemia.

Risk factors for rebleeding in patients with obscure gastrointestinal bleeding from southern China

Background To identify the risk factors associated with rebleeding in obscure gastrointestinal bleeding (OGIB) patients from southern China. Methods This retrospective study involved 229 patients who underwent small bowel endoscopy in our hospital between 1 January 2018 and 1 December 2020. The clinical characteristics and risk factors related to rebleeding were retrospectively evaluated. Results Rebleeding patients were significantly older than non-rebleeding patients (53.0 ± 15.9 vs. 46.2 ± 17.8 years), had lower hemoglobin concentrations (89.2 ± 28.1 vs. 126.2 ± 25.1 g/L), and higher blood urea nitrogen concentrations (5.4 ± 2.6 vs. 4.5 ± 2.2 µmol/L), respectively. A higher percentage of rebleeding patients had diabetes mellitus (13.9% vs. 2.9%) and overt bleeding (70.4% vs. 38.6%), and required blood transfusions (43.1% vs. 8.0%), compared with non-rebleeding patients, respectively. Multivariate logistic analysis indicated that drinking alcohol (odds ratio (OR): 9.27; 95% confidence interval (CI) = 1.35–63.78), anemia (OR: 17.38; 95% CI = 5.48–55.10), and blood transfusion (OR: 3.76; 95% CI = 1.04–13.56) increased the risk of rebleeding in OGIB patients. Conclusion Our data suggested that OGIB patients who drink alcohol, have anemia, and require blood transfusion have an increased risk of rebleeding.

Diagnostic Performance of Esophagogastroduodenoscopy, Colonoscopy, and Small Bowel Endoscopy in Thai Adults with Chronic Diarrhea

Background: Gastrointestinal endoscopy is recommended to investigate chronic diarrhea in Western countries, but its benefits have infrequently been investigated in Southeast Asia. This study aimed to determine the diagnostic utility of esophagogastroduodenoscopy (EGD), colonoscopy, and small bowel endoscopy in Thai chronic diarrhea. Methods: Medical records of consecutive patients who underwent EGD and/or colonoscopy to investigate chronic diarrhea at our center from 2008 to 2012 were reviewed. We also evaluated consecutive patients with negative EGD and colonoscopy who underwent subsequent small bowel endoscopy, including push enteroscopy, balloon-assisted enteroscopy (BAE), and video capsule endoscopy (VCE), from 2008 to 2018. The diagnostic yield of each endoscopic modality was analyzed. Results: A total of 272 patients underwent EGD and/or colonoscopy. Mean hemoglobin and albumin levels were 11.6 g/dL and 3.8 g/dL, respectively. EGD and colonoscopy were performed in 135 and 269 patients, respectively, and the diagnostic yield was 5.9% for EGD and 42.7% for colonoscopy. No patient with normal colonoscopy had positive EGD findings. Thirty-nine patients with normal EGD and colonoscopy underwent small bowel endoscopy. Mean hemoglobin and albumin levels were 10.9 and 2.7 g/dL, respectively. Push enteroscopy, BAE, and VCE were performed in 22, 20, and 11 patients with a diagnostic yield of 22.7%, 60.0%, and 45.5%, respectively. Conclusion: Colonoscopy was shown to be an essential investigation in chronic diarrhea. In contrast to western, EGD did not add benefit to colonoscopy. Enteroscopy played an important role in the diagnosis of chronic diarrhea when colonoscopy was negative.

Role of Small Bowel Endoscopy in Diagnosis and Management of Inflammatory Bowel Disease: Current Perspective

The evaluation of small bowel in inflammatory bowel disease (IBD) is mainly performed in cases with newly diagnosed or suspected Crohn’s disease (CD). The available modalities for small bowel evaluation include radiological imaging (barium meal follow through, magnetic resonance enteroclysis, computed tomography enteroclysis) and small bowel endoscopy also known as enteroscopy. The main advantage of small bowel endoscopy over radiological imaging is that it allows for obtaining biopsy specimen required for histological confirmation of the diagnosis. Various endoscopic modalities for endoscopic evaluation of small bowel include push enteroscopy and device assisted enteroscopy (DAE). Push enteroscopy allows only limited evaluation of proximal small bowel. Therefore, DAE is generally preferred over push enteroscopy for small bowel evaluation. DAE includes single balloon enteroscopy, double balloon enteroscopy, and spiral enteroscopy. The available literature suggests that there is no significant difference in the diagnostic yield among the available DAE devices. Therefore, the choice of DAE is largely dependent on the availability as well as local expertise. More recently, motorised spiral enteroscopy has been introduced. The main advantage of this novel DAE is ease of use with the possibility of evaluating the entire small bowel via per-oral route. However, the data regarding the use of motorised spiral enteroscopy is limited and comparative trials are required in future.

Early Recognition and Management of Small Bowel Perforation

Enteroscopy has a procedure-related perforation rate from less than 1% to 6.5%. It seems to be higher in therapeutic enteroscopy, especially polypectomy of large polyps, and in patients who have altered surgical anatomy. Early recognition is life-saving and studies have shown that if surgery is done within 12 hours of perforation the prognosis is better. In a patient who has undergone small bowel endoscopy the diagnosis of small bowel perforation should be suspected if the patient has acute pain in the abdomen. Early diagnosis should be the goal with prompt surgical correction.

Gastrointestinal haemorrhage

This chapter covers core curriculum topics relating to gastrointestinal haemorrhage. This includes risk assessment for upper gastrointestinal haemorrhage incorporating natural history and prediction of rebleed following peptic ulcer bleeding. Comprehensive coverage of assessment and management of variceal bleeding (gastric and oesophageal) is included including the role of stenting. Causes of presentations with lower gastrointestinal bleeding, including following radiotherapy, are presented along with guidance on assessing shock index, investigation and management strategies. The role of acute imaging versus endoscopic intervention is discussed. Furthermore, investigation and management of obscure and occult gastrointestinal bleeding is covered including small bowel endoscopy and specialist imaging. Additional curriculum material regarding gastrointestinal haemorrhage will also be covered in the mock examination chapter.

Artificial Intelligence in Small Bowel Endoscopy: Current Perspectives and Future Directions

Artificial intelligence (AI) is a computer system that is able to perform tasks which normally require human intelligence. The role of AI in the field of gastroenterology has been gradually evolving since its inception in the 1950s. Discovery of wireless capsule endoscopy (WCE) and balloon enteroscopy (BE) has revolutionized small gut imaging. While WCE is a relatively patient-friendly and noninvasive mode to examine the nonobstructed small gut, it is limited by a lengthy examination time and the need for expertise in reading images acquired by the capsule. Similarly, BE, despite having the advantage of therapeutic intervention, is costly, invasive, and requires general sedation. Incorporation of concepts like machine learning and deep learning has been used to handle large amounts of data and images in gastroenterology. Interestingly, in small gut imaging, the application of AI has been limited to WCE only. This review was planned to examine and summarize available published data on various AI-based approaches applied to small bowel disease. We conducted an extensive literature search using Google search engine, Google Scholar, and PubMed database for published literature in English on the application of different AI techniques in small bowel endoscopy, and have summarized the outcome and benefits of these applications of AI in small bowel endoscopy. Incorporation of AI in WCE has resulted in significant advancements in the detection of various lesions starting from dysplastic mucosa, inflammatory and nonmalignant lesions to the detection of bleeding with increasing accuracy and has shortened the lengthy review time in image analysis. As most of the studies to evaluate AI are retrospective, the presence of inherent selection bias cannot be excluded. Besides, the interpretability (black-box nature) of AI models remains a cause for concern. Finally, issues related to medical ethics and AI need to be judiciously addressed to enable its seamless use in future.

The vibro-impact capsule system in millimetre scale: numerical optimisation and experimental verification

The vibro-impact capsule system has been studied extensively in the past decade because of its research challenges as a piecewise-smooth dynamical system and broad applications in engineering and healthcare technologies. This paper reports our team’s first attempt to scale down the prototype of the vibro-impact capsule to millimetre size, which is 26 mm in length and 11 mm in diameter, aiming for small-bowel endoscopy. Firstly, an existing mathematical model of the prototype and its mathematical formulation as a piecewise-smooth dynamical system are reviewed in order to carry out numerical optimisation for the prototype by means of path-following techniques. Our numerical analysis shows that the prototype can achieve a high progression speed up to 14.4 mm/s while avoiding the collision between the inner mass and the capsule which could lead to less propulsive force on the capsule so causing less discomfort on the patient. Secondly, the experimental rig and procedure for testing the prototype are introduced, and some preliminary experimental results are presented. Finally, experimental results are compared with the numerical results to validate the optimisation as well as the feasibility of the vibro-impact technique for the potential of a controllable endoscopic procedure.