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DOI: 10.1055/s-2005-861419
Video Capsule Endoscopy for Investigation of Obscure Gastrointestinal Bleeding: Feasibility, Results, and Interobserver Agreement
C. Cellier, M. D.
Service d’Hépatogastroentérologie · Hôpital Européen Georges Pompidou
20 Rue Leblanc · 75908 Paris Cédex 15 · France
Fax: + 33-1-5609-3529
Email: Christophe.CELLIER@hop.egp.ap-hop-paris.fr
Publication History
Submitted 27 June 2004
Accepted after Revision 26 January 2005
Publication Date:
11 July 2005 (online)
Background and Study Aims: The aim of the study was to assess the feasibility, diagnostic yield, and interobserver
agreement of capsule endoscopy in the investigation of patients with obscure or occult
gastrointestinal bleeding.
Patients and Methods: A total of 64 consecutive patients with occult bleeding (31 %) or overt bleeding
(69 %) were assessed using capsule endoscopy after negative upper and lower endoscopy
and small-bowel radiology. The quality of visualization of the small-bowel mucosa
was scored from 1 (poor) to 4 (excellent). Thirty video capsule recordings with normal
or abnormal findings were blindly assessed by four independent endoscopists. Interobserver
agreement was evaluated using the kappa index.
Results: The small bowel was completely visualized in 57/64 patients (89 %). Incomplete small-bowel
transit was most commonly due to prolonged gastric retention (five patients). The
mucosa visualization scores (means) for the proximal, middle, and distal thirds of
the small bowel were 3.7, 3.3, and 2.2 respectively. Visualization of the distal ileum
was good (≥ 3) in 38 % and a bleeding site was found in 45 % of patients. Push-enteroscopy
was also performed in 56 patients. The results of the two techniques were similar
in 37 patients, capsule endoscopy was superior in 12 patients, and push-enteroscopy
was superior in seven patients. Interobserver agreement was good for bleeding and
for angiodysplasia, but poor for ulcers and tumors. Mean interobserver agreement was
better among experienced endoscopists than among junior endoscopists.
Conclusions: Capsule endoscopy allowed the whole small intestine to be explored in 89 % of patients,
with good visualization of the mucosa, except distally. Interobserver agreement was
better among the experienced endoscopists and was better for red-colored abnormalities
(bleeding and angiodysplasia) than for ulcers and tumors.
Introduction
In 5 - 40 % of patients with gastrointestinal bleeding, the underlying cause remains undetected after upper gastrointestinal endoscopy and colonoscopy [1] [2]. In most of these patients the source of bleeding is in the small intestine.
Radiological methods of screening the small intestine include small-bowel barium follow-through and abdominal computed tomography with enteroclysis, but the diagnostic value of these methods remains limited in gastrointestinal bleeding of obscure origin. Diagnostic endoscopic procedures include push-enteroscopy and capsule endoscopy. Push-enteroscopy can identify small-intestinal lesions which are potentially responsible for bleeding in 20 - 50 % of patients with obscure bleeding [3] [4] [5] [6] [7]. Capsule endoscopy is a new, noninvasive technique which appears to be more sensitive than push-enteroscopy in the investigation of obscure digestive bleeding [8] [9] [10] [11] [12]. Image interpretation may be difficult, however, and capsule endoscopy has rarely been evaluated in terms of the quality of visualization of the small-bowel mucosa it provides or interobserver variability.
The aim of this study was to assess the feasibility of using capsule endoscopy for investigating patients with obscure or occult gastrointestinal bleeding, in terms of imaging quality and completeness of the small-bowel examination, the diagnostic yield, and the level of interobserver agreement.
#Patients and Methods
#Patients
From January 2002 to December 2003, 64 consecutive patients were examined by capsule endoscopy because of recurrent occult (31 %) or overt (69 %) gastrointestinal bleeding (36 men, 28 women; mean age 57 ± 14 years). All patients with occult bleeding had recurrent iron-deficiency anemia despite treatment with iron supplementation, and had no evidence of inadequate iron intake and no excessive gynecological bleeding or evidence of malabsorption. The patients with overt gastrointestinal bleeding had presented with melena, which was associated with hematochezia in nine patients. The mean lowest hemoglobin level recorded was 6.8 ± 2.2 g/dl and the mean number of blood units transfused was 4.8 ± 2.4. All the patients had previously undergone upper endoscopy (with duodenal biopsy in patients with occult bleeding), complete colonoscopy, and small-bowel barium follow-through or abdominal computed tomography with enteroclysis, which had all failed to provide a diagnosis. Push-enteroscopy had been performed in 18 of the 64 patients (28 %) within the previous 6 months and had been reported as normal in all 18 cases. Meckel’s scintigraphy was performed in six patients who were aged under 30 years and this investigation was negative in all six. There were no contraindications to the use of the Given M2A capsule (intestinal obstruction or strictures, cardiac pacemakers, or pregnancy).
#Capsule Endoscopy Procedure
We used the Given M2A wireless video capsule system (Given Diagnostic Imaging System, Given Imaging Ltd., Yoqneam, Israel), which comprises: the M2A capsule, which acquires the images of the gastrointestinal tract; the Given Data Recorder for recording data transmitted by the M2A capsule; Rapid Application software, for viewing and reporting images and data acquired throughout the gastrointestinal tract.
Patients fasted for 8 hours before swallowing the capsule. An oral purge (with 1 liter of polyethylene glycol solution) was given the evening before capsule ingestion. Once the system had been set up and the capsule swallowed, patients were observed for 8 hours in hospital before the system was removed. Because the capsule was retained in the stomach for more than 8 hours in two of the first four patients, a plain abdominal radiograph was obtained 2 hours after ingestion in the subsequent patients in order to locate the capsule (n = 60, 94 %). Erythromycin 250 mg was infused over a 30-minute period in five patients who had suspected gastric retention (8 %). If gastric clearance was confirmed radiologically, patients were allowed to drink fluids after 2 hours and to eat a light brunch after 4 hours.
#Evaluation
Feasibility and tolerance: During the test, patients noted the time and nature of events such as drinking, eating, and unusual sensations. The patients were instructed to check for capsule excretion within 72 hours. If the capsule was not excreted, a plain abdominal radiograph was taken. Capsule transit times were determined by image analysis, and prolonged gastric retention was defined as a gastric transit time of more than 2 hours. Capsule images were reviewed by two physicians (A.L., J.E.). Decisions regarding whether to organise further investigations (push-enteroscopy, intraoperative endoscopy) or simply to follow the patients up clinically were made after capsule endoscopy.
In the first 40 patients the quality of visualization of the proximal, middle, and distal thirds of the small-bowel mucosa was scored as 1 (poor), 2 (mild), 3 (good), or 4 (excellent). The location of the capsule in the small bowel was defined by the capsule transit time.
Diagnostic yield: The diagnostic yield of capsule endoscopy was assessed by two gastroenterologists who were trained in push-enteroscopy (A.L., J.E.). Only lesions with a high potential for bleeding (as defined by Saurin et al. [9]), were considered. Other tests performed were recorded for each patient.
Interobserver agreement: To determine interobserver agreement, a total of 30 normal or abnormal capsule endoscopy video recordings (duration 2 minutes) were blindly assessed by four independent endoscopists (two juniors, T.L. and P.S., and two seniors, B.L. and C.C.). The junior endoscopists’ push-enteroscopy experience ranged from 1 year to 3 years (10 - 50 examinations) and the senior endoscopists both had more than 5 years’ experience (> 100 examinations). Before the reading session, each observer reviewed a film of each elementary lesion and of a normal bowel. The elementary diagnoses were ulcer, tumor, angiodysplasia, bleeding, and ”normal”.
Statistical analysis: The χ² test and the Mann-Whitney U test were used to identify significant differences (P values less than 0.05). Quantitative data were expressed as means ± SD. Interobserver agreement on qualitative variables was evaluated by using the kappa (κ) index as proposed by Fleiss [13]. This method measures agreement independently of concordant results that would be obtained purely by chance. Null kappa values correspond to an absence of agreement; negative values correspond to disagreement (complete if κ = - 1); and positive values correspond to agreement, which may be fair (κ < 0.40), fair to good (κ values 0.40 - 0.75), or excellent (κ > 0.75). In addition to kappa values, the corresponding 95 % confidence intervals (CI) were recorded according to the presence or absence of a sign (as proposed by Grant for binary data [14]).
#Results
#Feasibility and Image Quality
All the patients were able to swallow the capsule. No unusual sensations or adverse events were reported. All patients excreted the capsule within 72 hours (confirmed by a plain abdominal radiograph in two patients). The mean gastric and small-intestinal transit times were 58 ± 98 minutes and 282 ± 96 minutes respectively.
The small bowel was completely visualized in 57 of the 64 patients (89 %). Examination of the small intestine was incomplete in seven patients (11 %). In five of these patients this was related to prolonged gastric retention (> 2 hours). Gastric retention of more than 8 hours’ duration was observed in two of the first four patients examined, so plain abdominal radiographs were obtained after 2 hours in all subsequent patients (n = 60, 90 %). Gastric retention was suspected in five patients. These five patients received erythromycin, and three of them had an incomplete small-bowel examination. In one patient who had an incomplete small-bowel examination, recording failed after 43 minutes: retrospective analysis of the Given record yielded no explanation. The seventh patient whose small-bowel examination was incomplete had a diffuse exudative enteropathy. In this patient, capsule endoscopic small-bowel examination was incomplete despite a short gastric transit time and a recording period of more than 8 hours.
The mean quality of visualization of the mucosa was scored as 3.7 ± 0.4 in the proximal third, 3.3 ± 0.6 in the middle third, and 2.2 ± 0.9 in the distal third of the small bowel. Visualization of the mucosa was considered to be ‘good’ (a score of 3) in the proximal small intestine in 94 % of patients, in the middle part in 85 % of patients, and in the distal part in 38 % of patients (P < 0.05). Poor image quality was mostly due to the presence of opaque intestinal fluid and debris in the intestinal lumen.
#Diagnostic Yield
As shown in Table [1], a bleeding site was found in 29 of the 64 patients (45 %), recorded as angiodysplasia (41 %), active bleeding (24 %), or an ulcer (35 %). The bleeding site was located in the stomach in one patient (3 %) and in the proximal, middle, and distal portions of the small intestine in 35 %, 24 %, and 38 % of patients respectively. Lesions were found in 30 % of patients with unexplained iron-deficiency anemia and in 52 % of patients with overt gastrointestinal bleeding (P = 0.17, see Table [2]).
| n | % | |
|
Findings Angiodysplasia Ulcer Active bleeding |
12 10 7 |
41 35 24 |
|
Location of bleeding site Stomach Proximal small bowel Middle small bowel Distal small bowel |
1 10 7 11 |
3 35 24 38 |
| No. of patients | Diagnostic yield | ||
| n | % | ||
| Overt bleeding | 44 | 23 | 52* |
| Occult bleeding | 20 | 6 | 30* |
| Total | 64 | 29 | 45 |
| * P = 0.17, overt bleeding vs. occult bleeding. | |||
Push-enteroscopy was performed in 56 of the 64 patients. This was performed before capsule endoscopy, when it was normal (n = 18), and/or after capsule endoscopy (n = 41). Comparing capsule endoscopy with push-enteroscopy:
-
The two procedures produced similar results in 37 patients: nine patients with angiodysplasia, one patient with small-bowel varices, one patient with a gastric ulcer, and 26 patients with no abnormalities. In one patient, whose push-enteroscopy and capsule endoscopy examinations were normal, intraoperative enteroscopy revealed a duodenal Dieulafoy ulcer.
-
Capsule endoscopy was more sensitive than push-enteroscopy in 12 patients: two patients with Meckel’s diverticulum, one patient with aphthous ileal ulcerations suggestive of Crohn’s disease, seven patients with angiodysplasia, and two patients with tumors in an area of ulceration which were suspected on capsule endoscopy and confirmed by computed tomography with enteroclysis.
-
Push-enteroscopy was more sensitive than capsule endoscopy in seven patients: one patient with a carcinoid tumor, two patients with previously missed gastric angiodysplasia, and one patient with small-bowel angiodysplasia. In one patient, a proximal small-bowel tumor suggested by capsule endoscopy (Figure [1]) was neither confirmed by push-enteroscopy nor by intraoperative enteroscopy. In the two patients with an 8-hour gastric retention time, the small bowel was not explored by capsule endoscopy.
Figure 1 A proximal small-bowel tumor was suspected on the basis of these capsule endoscopy appearances. This was not confirmed by push-enteroscopy or abdominal computed tomography with enteroclysis, or at intraoperative enteroscopy.
Follow-up data were available for 48 patients (75 %), 36 patients with overt bleeding of obscure origin and 12 patients with occult bleeding of obscure origin. The mean follow-up time after the procedure was 13 months (range 3 - 26 months). It was not possible to follow up 16 patients who had been referred from other, distant hospitals. The bleeding resolved in 29 patients with overt bleeding (81 %) after endoscopic treatment (n = 16), medical therapy (n = 2), or surgical treatment (n = 4), or spontaneously (n = 7); and in eight patients with occult bleeding (67 %) after endoscopic treatment (n = 2), medical therapy (n = 1), or surgical treatment (n = 2), or spontaneously (n = 3).
#Interobserver Agreement
The agreement indexes for all the patients and observers are shown in Table [3]. Interobserver agreement was good for bleeding and angiodysplasia, but poor for ulcers and tumors. The mean interobserver agreement was significantly better among senior endoscopists than among junior endoscopists.
| Bleeding | Angiodysplasia | Tumor | Ulcer | Total | ||||||
| κ | 95 % CI | κ | 95 % CI | κ | 95 % CI | κ | 95 % CI | κ | 95 % CI | |
| All endoscopists | 0.69 | 0.55 to 0.83 | 0.46 | 0.32 to 0.60 | - 0.05 | - 0.19 to 0.09 | 0.21 | 0.07 to 0.35 | 0.51 | 0.37 to 0.65 |
| Senior endoscopists | 0.71 | 0.61 to 0.81 | 0.71 | 0.61 to 0.81 | N.D. | N.D. | 0.19 | 0.05 to 0.24 | 0.61 | 0.53 to 0.69 |
| Junior endoscopists | 0.56 | 0.44 to 0.68 | 0.22 | 0.10 to 0.34 | N.D. | N.D. | 0.07 | - 0.07 to 0.21 | 0.37 | 0.29 to 0.45 |
| N.D., not determined (calculation not possible because of low prevalence). | ||||||||||
Discussion
Capsule endoscopy is safe and comfortable for the patient [8] [9] [10] [11] [12] [15] [16], but its feasibility has not yet been fully evaluated. A few technical problems have been attributed to battery dysfunction [15]. In our study, 11 % patients had incomplete small-bowel studies because of gastric retention, capsule technical failure, or diffuse exudative enteropathy. Pennazio et al. [16] reported incomplete small-bowel studies in 21 % of patients, due to gastric retention, strictures, obstructing tumors, or technical failure. Plain abdominal radiographs should not be used systematically to diagnose capsule retention, as this is unnecessary in up to 92 % of patients. However, it may be considered for selected patients with risk factors for delayed gastric emptying, such as diabetes. In our study, patients received a prokinetic agent if the capsule seemed to be located epigastrically on the radiograph. Routine prokinetic treatment after capsule swallowing has been proposed but this seems to have a negative effect on the quality of visualization in the small intestine [17].
The quality of visualization of the small-bowel mucosa was generally good in our series but was often poor in the distal part. This was due to the presence of opaque intestinal fluid and food debris. All the patients received an oral purge with one liter of polyethylene glycol solution the day before capsule endoscopy. This seems to slow small-bowel transit [17], but its impact on the quality of visualization needs to be studied.
The investigation of obscure gastrointestinal bleeding is a major challenge. In all but one study reported to date, capsule endoscopy was the most efficient diagnostic tool, with a significantly higher diagnostic yield (40 % - 88 %) than push-enteroscopy (20 % - 50 %) [8] [9] [10] [11] [12]. In our series, the overall diagnostic yield was 45 %. It is noteworthy that we only considered lesions with a high potential for bleeding, as defined by Saurin et al. [9]. Our low detection rate of intestinal lesions by capsule endoscopy may be explained by our selection criteria (normal push-enteroscopy before inclusion in 28 % of patients) and by the fact that we did not compare the diagnostic yields of the two techniques.
As observed in other series, capsule endoscopy is particularly efficient (and better than push-enteroscopy) at detecting lesions located in the middle or distal small bowel. In our study, active bleeding was observed in seven out of 64 patients (11 %), and was seen in 24 % of patients with detected bleeding sites. This high percentage is probably explained by the fact that our hospital is a tertiary referral center for gastrointestinal bleeding and a majority of the patients included in the study had active overt bleeding. In these seven patients with active bleeding, angiodysplasia was detected by push-enteroscopy in five patients and a Meckel’s diverticulum was diagnosed by abdominal computed tomography with enteroclysis in the other two. The diagnostic yield of capsule endoscopy was somewhat higher in patients with overt bleeding than in patients with isolated iron-deficiency anemia in our study (52 % vs. 30 %, P = 0.17), a finding also reported by Pennazio et al. [16].
To our knowledge, this is the first study of the variability of capsule endoscopy image interpretation. Interobserver agreement was good for bleeding and angiodysplasia, but poor for ulcers and tumors, probably because the recognition of red color is easier than relief analysis. However, the poor kappa value observed for tumors should be interpreted with caution, as only one patient in our study had this lesion. Mergener & Enns [18] reported 100 % interobserver agreement for bleeding, but did not provide kappa values. Interestingly, we observed an “experience effect”, with better mean agreement among senior endoscopists than among junior endoscopists.
In conclusion, capsule endoscopy permitted complete exploration of the small bowel in 89 % of our patients. Incomplete small-bowel transit was mostly due to prolonged gastric retention. The images of the small-bowel mucosa obtained by capsule endoscopy were good, except in the distal part. Concordance among observers was better for red-colored abnormalities (bleeding and angiodysplasia) than for abnormalities in relief (ulcers and tumors). Capsule recordings are best reviewed by endoscopists trained in push-enteroscopy.
#References
- 1 Bouhnik Y, Nahon S, Landi B. Synopsis: diagnosis and treatment of occult digestive tract bleeding. Gastroenterol Clin Biol. 2000; 24 317-323
- 2 Waye J D. Small-intestinal endoscopy. Endoscopy. 2001; 33 24-30
- 3 Barkin J S, Lewis B S, Reiner D K. et al . Diagnostic and therapeutic jejunoscopy with a new, longer enteroscope. Gastrointest Endosc. 1992; 38 55-58
- 4 Barkin J S, Chong J, Reiner D K. First-generation video enteroscope: fourth-generation push-type small bowel enteroscopy utilizing an overtube. Gastrointest Endosc. 1994; 40 743-747
- 5 Berner J S, Mauer K, Lewis B S. Push and sonde enteroscopy for the diagnosis of obscure gastrointestinal bleeding. Am J Gastroenterol. 1994; 89 2139-2142
- 6 Chong J, Tagle M, Barkin J S, Reiner D K. Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology. Am J Gastroenterol. 1994; 89 2143-2146
- 7 Landi B, Tkoub M, Gaudric M. et al . Diagnostic yield of push-type enteroscopy in relation to indication. Gut. 1998; 42 421-425
- 8 Ell C, Remke S, May A. et al . The first prospective controlled trial comparing wireless capsule endoscopy with push-enteroscopy in chronic gastrointestinal bleeding. Endoscopy. 2002; 34 685-689
- 9 Saurin J C, Delvaux M, Gaudin J L. et al . Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push-enteroscopy. Endoscopy. 2003; 35 576-584
- 10 Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push-enteroscopy in patients with gastroscopy- and colonoscopy-negative gastrointestinal bleeding. Gut. 2003; 52 1122-1126
- 11 Lewis B S, Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: results of a pilot study. Gastrointest Endosc. 2002; 56 349-353
- 12 Hartmann D, Schilling D, Bolz G. et al . Capsule endoscopy versus push-enteroscopy in patients with occult gastrointestinal bleeding. Z Gastroenterol. 2003; 413 77-82
- 13 Fleiss J L.
The measurement of interrater agreement. In: Statistical methods for rates and proportions. New York; Wiley & Sons Inc 1981: 212-236 - 14 Grant J M. The fetal heart rate trace is normal, isn’t it?. Lancet. 1991; 337 215-218
- 15 Costamagna G, Shah S K, Riccioni M E. et al . A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease. Gastroenterology. 2002; 123 999-1005
- 16 Pennazio M, Santucci R, Rondonotti E. et al . Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology. 2004; 126 643-653
- 17 Fireman Z, Paz D. Capsule endoscopy: improving the transit time and the image view [abstract]. Gastrointest Endosc. 2004; 59 AB173
- 18 Mergener K, Enns R. Interobserver variability for reading capsule endoscopy examinations [abstract]. Gastrointest Endosc. 2003; 57 AB85
C. Cellier, M. D.
Service d’Hépatogastroentérologie · Hôpital Européen Georges Pompidou
20 Rue Leblanc · 75908 Paris Cédex 15 · France
Fax: + 33-1-5609-3529
Email: Christophe.CELLIER@hop.egp.ap-hop-paris.fr
References
- 1 Bouhnik Y, Nahon S, Landi B. Synopsis: diagnosis and treatment of occult digestive tract bleeding. Gastroenterol Clin Biol. 2000; 24 317-323
- 2 Waye J D. Small-intestinal endoscopy. Endoscopy. 2001; 33 24-30
- 3 Barkin J S, Lewis B S, Reiner D K. et al . Diagnostic and therapeutic jejunoscopy with a new, longer enteroscope. Gastrointest Endosc. 1992; 38 55-58
- 4 Barkin J S, Chong J, Reiner D K. First-generation video enteroscope: fourth-generation push-type small bowel enteroscopy utilizing an overtube. Gastrointest Endosc. 1994; 40 743-747
- 5 Berner J S, Mauer K, Lewis B S. Push and sonde enteroscopy for the diagnosis of obscure gastrointestinal bleeding. Am J Gastroenterol. 1994; 89 2139-2142
- 6 Chong J, Tagle M, Barkin J S, Reiner D K. Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology. Am J Gastroenterol. 1994; 89 2143-2146
- 7 Landi B, Tkoub M, Gaudric M. et al . Diagnostic yield of push-type enteroscopy in relation to indication. Gut. 1998; 42 421-425
- 8 Ell C, Remke S, May A. et al . The first prospective controlled trial comparing wireless capsule endoscopy with push-enteroscopy in chronic gastrointestinal bleeding. Endoscopy. 2002; 34 685-689
- 9 Saurin J C, Delvaux M, Gaudin J L. et al . Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push-enteroscopy. Endoscopy. 2003; 35 576-584
- 10 Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push-enteroscopy in patients with gastroscopy- and colonoscopy-negative gastrointestinal bleeding. Gut. 2003; 52 1122-1126
- 11 Lewis B S, Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: results of a pilot study. Gastrointest Endosc. 2002; 56 349-353
- 12 Hartmann D, Schilling D, Bolz G. et al . Capsule endoscopy versus push-enteroscopy in patients with occult gastrointestinal bleeding. Z Gastroenterol. 2003; 413 77-82
- 13 Fleiss J L.
The measurement of interrater agreement. In: Statistical methods for rates and proportions. New York; Wiley & Sons Inc 1981: 212-236 - 14 Grant J M. The fetal heart rate trace is normal, isn’t it?. Lancet. 1991; 337 215-218
- 15 Costamagna G, Shah S K, Riccioni M E. et al . A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease. Gastroenterology. 2002; 123 999-1005
- 16 Pennazio M, Santucci R, Rondonotti E. et al . Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology. 2004; 126 643-653
- 17 Fireman Z, Paz D. Capsule endoscopy: improving the transit time and the image view [abstract]. Gastrointest Endosc. 2004; 59 AB173
- 18 Mergener K, Enns R. Interobserver variability for reading capsule endoscopy examinations [abstract]. Gastrointest Endosc. 2003; 57 AB85
C. Cellier, M. D.
Service d’Hépatogastroentérologie · Hôpital Européen Georges Pompidou
20 Rue Leblanc · 75908 Paris Cédex 15 · France
Fax: + 33-1-5609-3529
Email: Christophe.CELLIER@hop.egp.ap-hop-paris.fr
Figure 1 A proximal small-bowel tumor was suspected on the basis of these capsule endoscopy appearances. This was not confirmed by push-enteroscopy or abdominal computed tomography with enteroclysis, or at intraoperative enteroscopy.