1. Capsule Endoscopy in Tamworth

2. True or False: “Capsule Endoscopy is a useful test in the diagnosis of unexplained anaemia” FALSE

3. Importance of Pre Test Probability MBS – Item Number 11820 MBS – Item Number 11820 obscure gastrointestinal bleeding, using a capsule endoscopy device approved by the Therapeutic Goods Administration (including administration of the capsule, imaging, image reading and interpretation, and all attendances for providing the service on the day the capsule is administered), (not being a service associated with double balloon enteroscopy), if: obscure gastrointestinal bleeding, using a capsule endoscopy device approved by the Therapeutic Goods Administration (including administration of the capsule, imaging, image reading and interpretation, and all attendances for providing the service on the day the capsule is administered), (not being a service associated with double balloon enteroscopy), if: (a) the service is performed by a specialist or consultant physician with endoscopic training that is recognised by The Conjoint Committee for the Recognition of Training in Gastrointestinal Endoscopy; and (a) the service is performed by a specialist or consultant physician with endoscopic training that is recognised by The Conjoint Committee for the Recognition of Training in Gastrointestinal Endoscopy; and (b) the patient to whom the service is provided: (b) the patient to whom the service is provided: (i) is aged 10 years or over; and (i) is aged 10 years or over; and (ii) has recurrent or persistent bleeding ; and (ii) has recurrent or persistent bleeding ; and (iii) is anaemic or has active bleeding ; and (iii) is anaemic or has active bleeding ; and (c) an upper gastrointestinal endoscopy and a colonoscopy have been performed on the patient and have not identified the cause of the bleeding ; and (c) an upper gastrointestinal endoscopy and a colonoscopy have been performed on the patient and have not identified the cause of the bleeding ; and (d) the service is performed within 6 months of the upper gastrointestinal endoscopy and colonoscopy (d) the service is performed within 6 months of the upper gastrointestinal endoscopy and colonoscopy

4. Understanding the “O’s” of GI Bleeding Obscure Obscure Cause not identified after endoscopies Cause not identified after endoscopies (up to10% - 75% will be due to small bowel lesions) Overt Overt Melaena or haematochezia Melaena or haematochezia Occult Occult Not Overt Not Overt In practice, obscure GI bleeding is either overt or causes iron deficiency

5. Diagnosing Iron Deficiency Iron Deficiency Systemic Disease Mixed Iron↓↓↓ Transferrin↑↓↓ Transferrin Saturation ↓ ↓ ↓ / N / ↑ ↓ Ferritin↓↑ Transferrin Receptor ↑N↑

6. Initial Iron Deficiency Workup Consider ExtraIntestinal Causes Consider ExtraIntestinal Causes Dietary Dietary Pregnancy, Lactation Pregnancy, Lactation Menstruation Menstruation Haemolysis Haemolysis Blood donation Blood donation Haematuria Haematuria

7. Initial Iron Deficiency Workup Consider ExtraIntestinal Causes Consider ExtraIntestinal Causes Gastroscopy Gastroscopy Ulcers, Malignancy, Angioectasia, GAVE Ulcers, Malignancy, Angioectasia, GAVE H. Pylori status H. Pylori status Duodenal biopsies for coeliac disease Duodenal biopsies for coeliac disease Colonoscopy Colonoscopy Malignancy, colitis, angioectasia, proctitis Malignancy, colitis, angioectasia, proctitis Include ileoscopy Include ileoscopy Good bowel preparation important Good bowel preparation important

8. Initial Iron Deficiency Workup If Endoscopies are non-diagnostic: If Endoscopies are non-diagnostic: Reconsider extraintestinal causes Reconsider extraintestinal causes Consider Urinalysis and Coeliac disease serology Consider Urinalysis and Coeliac disease serology Iron Replacement OR Early Capsule Endoscopy Iron Replacement OR Early Capsule Endoscopy

9. Iron Replacement OR Early Capsule Endoscopy Iron Replacement Iron Replacement Younger Younger Premenopausal Premenopausal Asymptomatic Asymptomatic Never overt bleeding Never overt bleeding Observe for at least 3 months then recheck Hb and ferritin. If “recurrent or persistent bleeding”, then capsule endoscopy Observe for at least 3 months then recheck Hb and ferritin. If “recurrent or persistent bleeding”, then capsule endoscopy Early Capsule Endoscopy Older Male Symptoms, Weight loss Any overt bleeding Need to demonstrate “recurrent or persistent bleeding” – eg 2 low Hb’s, a positive FOBT after endoscopies etc

10. Capsule Endoscopy Preparation Similar to colonoscopy Similar to colonoscopy Stop iron tablets 5 days prior Stop iron tablets 5 days prior Clear fluids afternoon before Clear fluids afternoon before 2 sachets of PicoPrep 2 sachets of PicoPrep 10 hour fast 10 hour fast On the day On the day Metoclopramide and simethicone Metoclopramide and simethicone

12. What Does Capsule Endoscopy Visualize in the Small Bowel? Melanoma Inflammation by infection (eg, CMV) Angioectasia Inflammatory stenosis Overt bleedingMass/tumor Ulcerated stenosis caused by NSAID use Bleeding ulcer

14. Yield of Capsule Endoscopy 38 – 83% 38 – 83% Depends largely on pre test probability Depends largely on pre test probability Of small bowel lesions found: Of small bowel lesions found: 60% angioectasia 60% angioectasia 30% ulcers / erosions 30% ulcers / erosions 10% tumours 10% tumours

15. Other Diagnostic Options Method Diagnostic Yield Considerations Standard Radiological Imaging Low: 5% (unable to diagnose most vascular lesions) Low: 5% (unable to diagnose most vascular lesions) Impact on management: <10% Impact on management: <10% Useful for clinical suspicion of small bowel obstruction, tumors Useful for clinical suspicion of small bowel obstruction, tumors Bleeding Scan Low: ~25% Low: ~25% Location accuracy: ~30–50% Location accuracy: ~30–50% Sensitivity threshold: 0.3 mL/min Sensitivity threshold: 0.3 mL/min Prerequisite to angiography Prerequisite to angiography Time-consuming Time-consuming Little or no benefit in typical OGIB Little or no benefit in typical OGIB Angiography Low: 25%–30% Low: 25%–30% Sensitivity threshold: 0.5 mL/h Sensitivity threshold: 0.5 mL/h Invasive Invasive Identifies bleeding/non-bleeding lesions Identifies bleeding/non-bleeding lesions Double-Balloon Enteroscopy 60%–80% 60%–80% Time-consuming Time-consuming Requires extensive training; additional nursing staff, anesthesiological support often required Requires extensive training; additional nursing staff, anesthesiological support often required Optimal patient selection required Optimal patient selection required

16. Diagnostic Options (continued) Method Diagnostic Yield Considerations Intraoperative Enteroscopy 70%–100% 70%–100% Transfusion-dependent (severe blood loss) Transfusion-dependent (severe blood loss) Risk of continued bleeding (outweighs risk of therapy) Risk of continued bleeding (outweighs risk of therapy) Technically difficult Technically difficult Adhesions, luminal blood, infiltrating neoplasia Adhesions, luminal blood, infiltrating neoplasia Complications (during and after procedure) Complications (during and after procedure) CT Enterography Low: vascular malformations, ulcerative disease Low: vascular malformations, ulcerative disease ~20% of submucosal lesions missed ~20% of submucosal lesions missed Push Enteroscopy 15%–35% average 15%–35% average Variable for overt bleeding and AVMs: 5%–65% Variable for overt bleeding and AVMs: 5%–65% May detect missed proximal lesions May detect missed proximal lesions Provides opportunity to identify and treat active bleeding (AVMs only) 25%– 85% of the time within a single year Provides opportunity to identify and treat active bleeding (AVMs only) 25%– 85% of the time within a single year Small Bowel CE 38%–83% 38%–83% Affects change in management in ≥87% of patients (50%–66% remain transfusion-free) Affects change in management in ≥87% of patients (50%–66% remain transfusion-free) Low re-bleeding rates in patients with negative findings of CE (5.6%–11%) Low re-bleeding rates in patients with negative findings of CE (5.6%–11%)

17. Complications Of Capsule Endoscopy Failure to enter the small bowel Failure to enter the small bowel Dyspahgia, Gastroparesis Dyspahgia, Gastroparesis Can insert endoscopically Can insert endoscopically Failure to visualise all small bowel Failure to visualise all small bowel 10-16% 10-16% Diabetics Diabetics Capsule Retention Capsule Retention <1% for OGIB, up to 10% for Crohn’s disease <1% for OGIB, up to 10% for Crohn’s disease Caution with previous small bowel surgery or abdominal radiotherapy or clinical suspicion of obstruction Caution with previous small bowel surgery or abdominal radiotherapy or clinical suspicion of obstruction DBE or surgery to remove capsule +/- resect lesion DBE or surgery to remove capsule +/- resect lesion

18. What to do with the Result Negative : Observe unless symptoms suggest further investigation Negative : Observe unless symptoms suggest further investigation Tumours : Consider resection Tumours : Consider resection Ulcers : Stop aspirin/NSAIDs, consider Crohn’s disease Ulcers : Stop aspirin/NSAIDs, consider Crohn’s disease Angioectasia : Angioectasia : Reassurance and Iron Replacement (safest) Reassurance and Iron Replacement (safest) Assess antiplatelet agents or anticoagulants Assess antiplatelet agents or anticoagulants If not controlled with iron, or intolerant of iron, then consider ablative therapy If not controlled with iron, or intolerant of iron, then consider ablative therapy

19. Via Gastroscopy, Enteroscopy or Colonoscopy

20. PatientHistologyCapsule Endoscopy QuartileSurgical Quartile 1Carcinoid44 2Adenocarcinoma44 3 11 4Gastrointestinal Stromal Tumour 32 5Adenocarcinoma11 6Cavernous Haemangioma 23 7Lymphoma11 8Gastrointestinal Stromal Tumour 32 9Adenocarcinoma44 10Gastrointestinal Stromal Tumour 21 11Hyperplastic polyp11 12Cavernous Haemangioma 32 13Ectopic Pancreas32 Identical quartile in 7/13 Different quartile by one in 6/13

21. Anterograde Push Enteroscopy

22. Other indications for Small Bowel Capsule Endoscopy Peutz-Jager syndrome Peutz-Jager syndrome Crohn’s disease* Crohn’s disease* Coeliac disease* Coeliac disease* Abnormal SB radiology* Abnormal SB radiology* * Not medicare rebateable

23. Other Types of Capsules Patency Capsule Patency Capsule Oesophageal Capsule Oesophageal Capsule Colonic capsule Colonic capsule

24. So how do I get one? Refer for a consultation Refer for a consultationOR Fax information across and I can have a look Fax information across and I can have a lookOR Refer directly yourself Refer directly yourself

25. Questions?