**8. Operative endoscopy**

Beside diagnostic endoscopy, operative endoscopy also has a determinant role in the practical management of IBD affected patients [3].

In particular, CD patients have an elevated risk of relapses in the sites of surgical anastomosis where strictures can appear [3]. At this level, pneumatic endoscopic dilatations (balloons of 12-18 mm with pressures of 25-50 psi are used) as well as the placement of coated stents are techniques of important efficacy for the rechanneling of severe strictures (early efficacy in 86% of cases; late efficacy in 55% of cases) [1].

Before the advent of pneumatic perendoscopic dilators, patients with significant strictures necessary underwent a surgical intervention of resection of intestinal segments, with a risk of short bowel syndrome [3].

The response to operative endoscopy techniques has been demonstrated significantly higher, observing a minor risk of surgical intervention in those cases with extension of the stricture being ≤ 4 cm [1]. A recent study by Stienecker K [11], examined 31 strictures in a group of CD affected patients: in 30 of them balloon dilatation was successful in a single

Endoscopy in Paediatric Inflammatory Bowel Disease (IBD) 249

Before the advent of video capsule endoscopy, the small bowel remained a "black box",

The advent of small-bowel capsule endoscopy (SBCE) allowed for the first time direct visualisation of the entire small bowel, albeit without the ability for tissue sampling [2]. This new technique has actually revolutionised the field of enteroscopy, offering a method for the complete evaluation of the small bowel. It is a non invasive technique, secure both for the paediatric and the adult patient, that overcomes the limitations of barium contrasted enteroscopy (low specificity for initial inflammatory lesions) and of ileum-colonoscopy

The lens with extremely short focus (1 mm) allows a very high precision of image, without

A recent metanalysis demonstrated the accuracy of video capsule endoscopy for the evaluation of the small bowel to be significantly superior to the one of enteroscopy and ileum-colonoscopy (63% vs 23% and 46% respectively); such a superiority is observed also with respect of other traditional techniques of imaging (i.e. TAC). Furthermore SBCE, can be

This technique is therefore efficacious for the identification of superficial lesions which are not radiologically visible and the localisation of which can not be explored through

It is important for the study of the small bowel diseases (particularly for CD and U-IBD) in which the localisation at the small bowel can represent the unique site of disease, with

The 2008 ECCO and OMED Consensus Statement [2] indicated that ileocolonoscopy must be performed prior to SBCE for the diagnosis of Crohn's disease. Small-bowel cross-sectional imaging should generally precede SBCE. The choice of radiographic imaging depends on

SBCE should be performed in children or adolescents with a high suspicion of Crohn's

Younger children, under 9 years in particular, cannot generally assume and swallow the capsule. Determinants are the dimensions of the child, in terms of compatibility between capsular dimensions and the oesophageal sphincters, pylorus and ileum-cecal valve. It is important to ascertain the swallowing capacity of the child through simulations, i.e. vitaminic capsules with comparable dimensions, before performing SBCE. A valid alternative is the insertion of the capsule (length 25,3 mm, diameter 11 mm, weight 3.7 g)

This technique is particularly efficacious for the identification of paediatric patients with suspicion of Crohn's disease manifesting a protein-loosing enteropathy and/or growth deficit, gastro-duodenal bleeding, malabsorption, chronic abdominal pain, chronic diarrhoea, anorexia, anemia, hypoalbuminemia, positive serology for ASCA (being negative or poorly significant the other exams of the diagnostic flow-chart i.e. EGDS, ileumcolonoscopy, abdominal radiography); in these cases, moreover, capular endoscopy results



disease, when conventional endoscopy and small-bowel imaging are normal.

directly in the duodenum, using a dedicated device to perform the insertion [12-13].

economic as a test to be performed as a first-line indication [11] [14].

manifesting unexplained signs and symptoms (i.e. anemia)

considered if ileocolonoscopy is contraindicated or unsuccessful)

Other applications of SBCE comprehend [2][14][15]:

being almost inaccessible to the paediatric endoscopists.

(which can at its best evaluate the terminal ileum) [13].

requiring inflation with air and with a resolution of 0.1 mm [14].

useful for diagnosis of diseases involving the right colon [13].

consequent difficulty for a correct diagnosis [12].

local availability and expertise.

endoscopy.

endoscopic session, so that eventually the strictures could be passed easily with the standard colonoscope. Sufficient dilatation was not possible in one patient with a long stricture of the ileum involving the Bauhin valve and an additional stricture of the ileum which were 15 cm apart. This patient therefore required surgery. Available follow-up was in the range of 54-118 months (mean 81). The relapse rate over this period was 46%, but 64% of relapsing strictures could be successfully dilated again. Only in four patients was surgery required during this follow-up period. These initial results support endoscopic balloon dilatation, especially for short strictures in Crohn's disease, perforation a rare complication.

In the long-term, the relapse rate is probably higher than after surgery, but usually a second endoscopic treatment can be performed successfully, leading to a considerable success rate of the endoscopic procedure. The overall technical success rate, defined as achieving an endoscopically passable residual stricture, is between 70% and 90 %, independent of the balloon's diameter having being used.

Indications to endoscopic dilatation of the strictures are [3]:


The dilatation is effectuated under deep sedation by insertion of the dilator across the stenosis and by inflation of the associated balloon with water and gastrographin in order to render it radio-opaque, therefore subjected to control [3]. Once the targeted diameter is reached, the balloon remains in loco for 1-2 minutes. An endoscopic control is usually performed one month later, in order to evaluate the diameter at the level of the precedent stenosis: if it is normal, a following endoscopic control is performed after 6 months whereas if the luminal diameter remains lower than 50% of the normal size, a new dilatation is programmed. The procedure should always be performed in a secure setting, in order to prevent the arousal of any complications [3].

The principle limitations to the use of endoscopy in paediatric age are mainly determined by the dimensions of the instrument [1].

Other frequently used endoscopic applications are: intra-operative ileoscopy (for the study of ileum during laparotomy), the removal of videocapsule (in cases when it is retained into the small bowel) and mucosal marking with china blue (to consent a major accuracy of the histological analysis) [1].

#### **9. Small bowel capsule endoscopy (SBCE)**

"Small-bowel capsule endoscopy (SBCE)" or "video capsule endoscopy" is a method of endoluminal examination of the small bowel using a wireless capsule shaped tool which is usually swallowed and then propelled through the gastrointestinal tract by gut motility.

Until a decade ago, mucosal visualization of the small bowel was limited to the reach of the push enteroscope as well as of the invasive and expensive intraoperative enteroscopy [2].

Even though push-enteroscopy has allowed us to access the visualization of the proximal jejunum extending the diagnostic potentialities of EGDS, it incidentally results in a relatively invasive technique [12]. Even more invasive is intra-operatory enteroscopy which in effect requires laparotomy and laparoscopy. Double-balloon enteroscopy allows a visualization of the entire bowel without necessity of surgical access, but requires a long time for manipulation.

endoscopic session, so that eventually the strictures could be passed easily with the standard colonoscope. Sufficient dilatation was not possible in one patient with a long stricture of the ileum involving the Bauhin valve and an additional stricture of the ileum which were 15 cm apart. This patient therefore required surgery. Available follow-up was in the range of 54-118 months (mean 81). The relapse rate over this period was 46%, but 64% of relapsing strictures could be successfully dilated again. Only in four patients was surgery required during this follow-up period. These initial results support endoscopic balloon dilatation, especially for short strictures in Crohn's disease, perforation a rare complication. In the long-term, the relapse rate is probably higher than after surgery, but usually a second endoscopic treatment can be performed successfully, leading to a considerable success rate of the endoscopic procedure. The overall technical success rate, defined as achieving an endoscopically passable residual stricture, is between 70% and 90 %, independent of the

The dilatation is effectuated under deep sedation by insertion of the dilator across the stenosis and by inflation of the associated balloon with water and gastrographin in order to render it radio-opaque, therefore subjected to control [3]. Once the targeted diameter is reached, the balloon remains in loco for 1-2 minutes. An endoscopic control is usually performed one month later, in order to evaluate the diameter at the level of the precedent stenosis: if it is normal, a following endoscopic control is performed after 6 months whereas if the luminal diameter remains lower than 50% of the normal size, a new dilatation is programmed. The procedure should always be performed in a secure setting, in order to

The principle limitations to the use of endoscopy in paediatric age are mainly determined by

Other frequently used endoscopic applications are: intra-operative ileoscopy (for the study of ileum during laparotomy), the removal of videocapsule (in cases when it is retained into the small bowel) and mucosal marking with china blue (to consent a major accuracy of the

"Small-bowel capsule endoscopy (SBCE)" or "video capsule endoscopy" is a method of endoluminal examination of the small bowel using a wireless capsule shaped tool which is usually swallowed and then propelled through the gastrointestinal tract by gut motility. Until a decade ago, mucosal visualization of the small bowel was limited to the reach of the push enteroscope as well as of the invasive and expensive intraoperative enteroscopy [2]. Even though push-enteroscopy has allowed us to access the visualization of the proximal jejunum extending the diagnostic potentialities of EGDS, it incidentally results in a relatively invasive technique [12]. Even more invasive is intra-operatory enteroscopy which in effect requires laparotomy and laparoscopy. Double-balloon enteroscopy allows a visualization of the entire bowel without necessity of surgical access, but requires a long time for

balloon's diameter having being used.


prevent the arousal of any complications [3].

**9. Small bowel capsule endoscopy (SBCE)** 

the dimensions of the instrument [1].

histological analysis) [1].

manipulation.


Indications to endoscopic dilatation of the strictures are [3]: - severe strictures, with proximal bowel dilatation


Before the advent of video capsule endoscopy, the small bowel remained a "black box", being almost inaccessible to the paediatric endoscopists.

The advent of small-bowel capsule endoscopy (SBCE) allowed for the first time direct visualisation of the entire small bowel, albeit without the ability for tissue sampling [2].

This new technique has actually revolutionised the field of enteroscopy, offering a method for the complete evaluation of the small bowel. It is a non invasive technique, secure both for the paediatric and the adult patient, that overcomes the limitations of barium contrasted enteroscopy (low specificity for initial inflammatory lesions) and of ileum-colonoscopy (which can at its best evaluate the terminal ileum) [13].

The lens with extremely short focus (1 mm) allows a very high precision of image, without requiring inflation with air and with a resolution of 0.1 mm [14].

A recent metanalysis demonstrated the accuracy of video capsule endoscopy for the evaluation of the small bowel to be significantly superior to the one of enteroscopy and ileum-colonoscopy (63% vs 23% and 46% respectively); such a superiority is observed also with respect of other traditional techniques of imaging (i.e. TAC). Furthermore SBCE, can be useful for diagnosis of diseases involving the right colon [13].

This technique is therefore efficacious for the identification of superficial lesions which are not radiologically visible and the localisation of which can not be explored through endoscopy.

It is important for the study of the small bowel diseases (particularly for CD and U-IBD) in which the localisation at the small bowel can represent the unique site of disease, with consequent difficulty for a correct diagnosis [12].

The 2008 ECCO and OMED Consensus Statement [2] indicated that ileocolonoscopy must be performed prior to SBCE for the diagnosis of Crohn's disease. Small-bowel cross-sectional imaging should generally precede SBCE. The choice of radiographic imaging depends on local availability and expertise.

SBCE should be performed in children or adolescents with a high suspicion of Crohn's disease, when conventional endoscopy and small-bowel imaging are normal.

Younger children, under 9 years in particular, cannot generally assume and swallow the capsule. Determinants are the dimensions of the child, in terms of compatibility between capsular dimensions and the oesophageal sphincters, pylorus and ileum-cecal valve. It is important to ascertain the swallowing capacity of the child through simulations, i.e. vitaminic capsules with comparable dimensions, before performing SBCE. A valid alternative is the insertion of the capsule (length 25,3 mm, diameter 11 mm, weight 3.7 g) directly in the duodenum, using a dedicated device to perform the insertion [12-13].

This technique is particularly efficacious for the identification of paediatric patients with suspicion of Crohn's disease manifesting a protein-loosing enteropathy and/or growth deficit, gastro-duodenal bleeding, malabsorption, chronic abdominal pain, chronic diarrhoea, anorexia, anemia, hypoalbuminemia, positive serology for ASCA (being negative or poorly significant the other exams of the diagnostic flow-chart i.e. EGDS, ileumcolonoscopy, abdominal radiography); in these cases, moreover, capular endoscopy results economic as a test to be performed as a first-line indication [11] [14].

Other applications of SBCE comprehend [2][14][15]:


Endoscopy in Paediatric Inflammatory Bowel Disease (IBD) 251

Principal contraindications to capsular endoscopy are suspected or known obstructions of the gastrointestinal tract because of an increased risk of retention of the capsule (incidence of

Causes of obstruction and consequent retention of the capsule can be primitive lesions of IBD, drug induced lesions (es. NSAD), radiation induced lesions and neoplastic lesions

In order to minimize the risk of capsule retention, an accurate anamnesis and clinical examination are fundamental. Any symptom possibly related to obstruction has to be identified, even though in most cases the capsule retention results asymptomatic [14]. Since the preliminary performance of enteroscopy for the evaluation of any possible stenosis does not exclude afterwards a capsule retention, the "patency capsule" appears, in stead, a more useful opportunity. It is made of lactose and barium, and begins to break up after the thirtieth hour: if its passage does not determine complications (the patient eliminates the capsule unbroken or the radio-frequencies emitted give out within thirty hours), then the

Extremely rare side effects of the patency capsule are abdominal pain and occasional

When the capsule is actually retained, an orally administered corticosteroid therapy

The incidence of capsule retention among patients with suspected CD is of 10% whereas it is



A patency (biodegradable, 'dummy') capsule to reduce the risk of retention should be

Passage of an intact patency capsule predicts safe transit of a small-bowel capsule of identical or lesser size. A patency capsule may itself cause obstruction at tight strictures, but this is usually transient. A retained small-bowel capsule can often be retrieved by DAE [2].

[1] Daperno M, D'Haens G, Van Assche G, Baert F, Bulois P, Maunoury V, Sostegni R, Rocca

[2] Bourreille A et al. Role of small-bowel endoscopy in IBD: international OMED–ECCO

R, Pera A, Gevers A, Mary JY, Colombel JF, Rutgeerts P: Development and validation of a new, simplified endoscopic activity score for Crohn's disease: the


0,75 -5%), recent surgical interventions and patients with pace-maker [14][16].

In the majority of cases, retentions are temporary and asymptomatic [14].

generally permits the progression of the capsule through the stricture [14].

In summary, as reported in the 2008 ECCO and OMED Consensus Statement [2]:

low and comparable to that when the indication for SBCE is bleeding.

entirely exclude the potential for small-bowel capsule retention [2].

SES –CD. *Gastrointestinal Endoscopy* 2004; 60: 505-12.

consensus. *Endoscopy 2009*; 41: 618–637


(mainly in the young adults with a longer follow-up) [14].

video capsule endoscopy can be safely performed [14][16].

temporary episodes of bowel occlusion.

of 4-7% among those with diagnosis of CD [14].

considered, or DAE, if strictures are identified [2].

**10. References** 


The fotographic objective, with angle of vision of 140^, permits an adequate visualization of the small bowel – considering the relative small diameter [12]. A complete evaluation of the gastrointestinal segments with major diameters, such as stomach and colon is in stead not possible.

Inside the capsule a coloured miniaturized camera, a battery and a transmission device are placed. Two images per second are acquired and sent, in form of radio waves, to 8 detection electrodes being placed on the abdominal surface of the patient and, from them, to an external recorder. The film on a monitor is then analyzed by the specialist. The duration of the test is of about 8 hours.

An adequate intestinal preparation to be effectuated the day before through assumption of iso-osmolar solutions at a dosage of 25-30 ml/Kg is recommended. It is in fact critically important for a good visualization of the small bowel mucosa [14]. Oral preparations of sodium-phosphate or poliethilenglicole (PEG) are used.

The administration of prokinetics may reduce transit times, increasing the complete evaluation of the small bowel. Randomized studies are nevertheless necessary to confirm their efficacy [14].

Patients should fast for at least 8 hours before the procedure and can start consuming liquids 1-2 hours after its begun; they can have light meals 2 hours after the ingestion of the capsule [14].

By the way, there is no available evidence to support a particular bowel preparation for SBCE in the subset of patients with suspected Crohn's disease [2]. The technique was approved by the American FDA in 2001 for adults and in 2003 for patients aging 10 to 18 years and presents a very low risk of complications. It can be performed for outpatients and does not expose to ionizing radiations, as it happens with the more common radiological techniques such as small bowel enema and abdominal TAC [8]. Also, small bowel lesions identified through capsular endoscopy are observed in 13% of normal asymptomatic adults, so they are not sufficient for a diagnosis of IBD. More importantly similar lesions are, identified in patients affected by Celiac Disease, allergic–infective-ischemic-rheumaticautoimmune enteropathy, in immunodeficiencies and in NSAD enteropathy [14-15].

Video capsule endoscopy is the most efficacious test for diagnosis of patients with symptomatic "occult" CD but it is unspecific and does not allow itself the differential diagnosis among the above-mentioned patterns [14].

In summary, as it is stated in the 2008 ECCO and OMED Consensus, SBCE is able to identify mucosal lesions compatible with Crohn's disease in some patients in whom conventional endoscopic and small-bowel radiographic imaging modalities have been non diagnostic. As with other imaging modalities, a diagnosis of Crohn's disease should not be based on the appearances at capsule endoscopy alone. A normal capsule endoscopy has a high negative predictive value for active small-bowel Crohn's disease [2].

Principle limitations of SBCE [2]:



The fotographic objective, with angle of vision of 140^, permits an adequate visualization of the small bowel – considering the relative small diameter [12]. A complete evaluation of the gastrointestinal segments with major diameters, such as stomach and colon is in stead not

Inside the capsule a coloured miniaturized camera, a battery and a transmission device are placed. Two images per second are acquired and sent, in form of radio waves, to 8 detection electrodes being placed on the abdominal surface of the patient and, from them, to an external recorder. The film on a monitor is then analyzed by the specialist. The duration of

An adequate intestinal preparation to be effectuated the day before through assumption of iso-osmolar solutions at a dosage of 25-30 ml/Kg is recommended. It is in fact critically important for a good visualization of the small bowel mucosa [14]. Oral preparations of

The administration of prokinetics may reduce transit times, increasing the complete evaluation of the small bowel. Randomized studies are nevertheless necessary to confirm

Patients should fast for at least 8 hours before the procedure and can start consuming liquids 1-2 hours after its begun; they can have light meals 2 hours after the ingestion of the

By the way, there is no available evidence to support a particular bowel preparation for SBCE in the subset of patients with suspected Crohn's disease [2]. The technique was approved by the American FDA in 2001 for adults and in 2003 for patients aging 10 to 18 years and presents a very low risk of complications. It can be performed for outpatients and does not expose to ionizing radiations, as it happens with the more common radiological techniques such as small bowel enema and abdominal TAC [8]. Also, small bowel lesions identified through capsular endoscopy are observed in 13% of normal asymptomatic adults, so they are not sufficient for a diagnosis of IBD. More importantly similar lesions are, identified in patients affected by Celiac Disease, allergic–infective-ischemic-rheumatic-

autoimmune enteropathy, in immunodeficiencies and in NSAD enteropathy [14-15].

Video capsule endoscopy is the most efficacious test for diagnosis of patients with symptomatic "occult" CD but it is unspecific and does not allow itself the differential

In summary, as it is stated in the 2008 ECCO and OMED Consensus, SBCE is able to identify mucosal lesions compatible with Crohn's disease in some patients in whom conventional endoscopic and small-bowel radiographic imaging modalities have been non diagnostic. As with other imaging modalities, a diagnosis of Crohn's disease should not be based on the appearances at capsule endoscopy alone. A normal capsule endoscopy has a high negative

U)

possible.

the test is of about 8 hours.

their efficacy [14].

capsule [14].


sodium-phosphate or poliethilenglicole (PEG) are used.

diagnosis among the above-mentioned patterns [14].

predictive value for active small-bowel Crohn's disease [2].


Principle limitations of SBCE [2]:




Principal contraindications to capsular endoscopy are suspected or known obstructions of the gastrointestinal tract because of an increased risk of retention of the capsule (incidence of 0,75 -5%), recent surgical interventions and patients with pace-maker [14][16].

Causes of obstruction and consequent retention of the capsule can be primitive lesions of IBD, drug induced lesions (es. NSAD), radiation induced lesions and neoplastic lesions (mainly in the young adults with a longer follow-up) [14].

In the majority of cases, retentions are temporary and asymptomatic [14].

In order to minimize the risk of capsule retention, an accurate anamnesis and clinical examination are fundamental. Any symptom possibly related to obstruction has to be identified, even though in most cases the capsule retention results asymptomatic [14].

Since the preliminary performance of enteroscopy for the evaluation of any possible stenosis does not exclude afterwards a capsule retention, the "patency capsule" appears, in stead, a more useful opportunity. It is made of lactose and barium, and begins to break up after the thirtieth hour: if its passage does not determine complications (the patient eliminates the capsule unbroken or the radio-frequencies emitted give out within thirty hours), then the video capsule endoscopy can be safely performed [14][16].

Extremely rare side effects of the patency capsule are abdominal pain and occasional temporary episodes of bowel occlusion.

When the capsule is actually retained, an orally administered corticosteroid therapy generally permits the progression of the capsule through the stricture [14].

The incidence of capsule retention among patients with suspected CD is of 10% whereas it is of 4-7% among those with diagnosis of CD [14].

In summary, as reported in the 2008 ECCO and OMED Consensus Statement [2]:


A patency (biodegradable, 'dummy') capsule to reduce the risk of retention should be considered, or DAE, if strictures are identified [2].

Passage of an intact patency capsule predicts safe transit of a small-bowel capsule of identical or lesser size. A patency capsule may itself cause obstruction at tight strictures, but this is usually transient. A retained small-bowel capsule can often be retrieved by DAE [2].
