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DOI: 10.1055/s-2005-870178
Small-Intestinal Pathology on Capsule Endoscopy: Inflammatory Lesions
M. Pennazio, M. D.
Gastroenterology Unit 2 · Department of Gastroenterology and Clinical Nutrition ·
S. Giovanni A.S. Hospital
Via Cavour 31 · 10123 Turin · Italy
Fax: 39-011-6333623 ·
Email: mpen60@yahoo.com
Publication History
Publication Date:
20 July 2005 (online)
This is the first of four articles dealing with pathology of the small intestine as seen at capsule endoscopy. These contributions will appear consecutively in the eighth to the eleventh issues of Endoscopy.
#Inflammatory Lesions
Capsule endoscopy is emerging as a first-line tool for diagnosing Crohn’s disease. It is known that diagnosis of this condition is frequently delayed due to the lack of sensitivity of conventional diagnostic methods, in particular in identifying the early stages of the disease. As seen in Cases 1 and 2, capsule endoscopy may reveal circumscribed alterations such as lymphangiectasia and villous denudation, which are apparently precursors of the typical aphthous lesions and which, in the appropriate clinical context, may be considered as early manifestations of Crohn’s disease. The endoscopic alterations of the mucosa more typical of the advanced stages of the disease are clear in Cases 1 and 3; they consist of scalloped or shallow aphthae, fissural ulcers, crater-like ulcers that may actively bleed, and fistulas. These lesions typically show a pattern of discontinuous involvement, with segments of altered mucosa and intervening segments of normal mucosa (”skip lesions”). Capsule endoscopy, in selected cases of Crohn’s disease, may also be one of the useful tools for monitoring the effectiveness of immunosuppressive treatment, as seen in Case 1.
As is shown in Cases 4 and 5, a promising application of capsule endoscopy is in evaluating intestinal damage due to nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation. In NSAID-induced enteropathy, endoscopy shows patchy redness, erosions, ulcers, and strictures which often cause weblike or membrane-like narrowing of the bowel lumen. In radiation enteritis, lymphangiectasia, neovascularization, and fibrotic strictures are seen. All findings are, however, nonspecific. It should be noted that, due to the increased risk of capsule impaction typical of these conditions, an intestinal stenosis must be ruled out before capsule endoscopy can be performed.
In autoimmune enteropathy the endoscopic aspect of mucosal atrophy is also nonspecific; capsule endoscopy may nevertheless be of use in monitoring the effects of therapy on the intestinal mucosa, as seen in Case 6.
It should be stressed that a capsule endoscopy finding of inflammatory and ulcerative lesions frequently poses the problem of differential diagnosis (Table [1]). There are no endoscopic characteristics peculiar to these lesions that are pathognomonic of a specific condition; whenever possible, histological confirmation of such lesions should be obtained.
| Crohn’s disease | Infections (cytomegalovirus, tuberculosis, Yersinia, typhoid, parasites) |
| Drugs (NSAIDs, chemotherapy, enteric-coated potassium) | Toxins (arsenic) |
| Mesenteric arterial insufficiency | Hyperacidity syndromes (Zollinger-Ellison syndrome, Meckel's diverticulum) |
| Vasculitis (SLE, rheumatoid, periarteritis nodosa) | Eosinophilic enteritis |
| Celiac disease | Uremia |
| Chronic ulcerative jejunoileitis | Behçet’s syndrome |
| Lymphoma, carcinoma | Idiopathic primary ulceration |
| Radiation injury | |
| NSAIDs, nonsteroidal anti-inflammatory drugs; SLE, systemic lupus erythematosus. | |
Case 1: Crohn's disease
W. Voderholzer
IV. Medizinische Klinik, Humboldt Universität Charité, Berlin, Germany
Figure 1 Jejunal Crohn’s disease: an ulcerous lesion on a mucosal crest is seen, near to a reddish area showing villous denudation.
Figure 2 The same patient as in Figure 1, with an ulcer in the jejunum before treatment with infliximab.
Figure 3 The jejunal ulcer after infliximab treatment.
Figure 4 Ileocolonoscopy of the same patient showed an aphthous lesion in the neoterminal ileum.
Figure 5 A fissural ulcer in the proximal ileum.
Figure 6 The same patient with inflammatory stenosis. The capsule passed through, causing pain for about 20 minutes.
Case 2: Ileal Crohn's disease
G. Gay
Department of Internal Medicine and Digestive Pathology, CHU de Nancy-Brabois, France
Figure 7 Ileal ulcerations highly suggestive of Crohn’s disease. The diagnosis was confirmed by ileal biopsies and perinuclear antineutrophil cytoplasmic antibody (P-ANCA) testing.
Figure 8 As Figure 7.
Case 3: Jejunal Crohn’s disease
M. Keuchel1, J. Gebhardt2, R. Sieslack3, W. -W. Höpker4, N. Breese2, W. Cordruwisch2, F. Hagenmüller1
1 First Medical Department, Allgemeines Krankenhaus Altona, Hamburg, Germany
2 Third Medical Department, Allgemeines Krankenhaus Barmbek, Hamburg, Germany
3 Department of Radiology, Allgemeines Krankenhaus Barmbek, Hamburg, Germany
4 Department of Pathology, Allgemeines Krankenhaus Barmbek, Hamburg, Germany
Figure 9 A 24-year-old man presented with abdominal pain, weight loss of 7 kg, fever, elevation of C-reactive protein and leucocyte levels, and iron-deficiency anemia. Esophagogastroduodenoscopy (EGD) and ileocolonoscopy were normal. Video capsule endoscopy (VCE) showed an aphthous ulcer of the proximal jejunum.
Figure 10 Fissural ulcer with surrounding inflammatory swelling, seen at VCE.
Figure 11 Mucosal edema with inflammatory stenosis. The distal ileum was normal. The capsule passed the small bowel without complications within 5 hours and 46 minutes.
Figure 12 An abdominal computed tomography (CT) scan showed a thickened jejunal loop (arrows). No stenosis was seen at enteroclysis.
Figure 13 Transabdominal ultrasonography in power Doppler mode demonstrated a thickened jejunal loop with hyperperfusion.
Figure 14 A jejunal biopsy taken at push-enteroscopy showed aphthous lesions (white arrows) and an epitheloid cell reaction (black arrow), consistent with Crohn’s disease (hematoxylin & eosin; × 10).
Case 4: NSAID enteropathy and stricture
J. M. Herrerías, Á. Caunedo, J. Romero
Gastroenterology Service, ”Virgen Macarena“ University Hospital, Seville, Spain
Figure 15 A 72-year-old woman with chronic use of NSAIDs presented with severe iron-deficiency anemia. Small-bowel follow-through, gastroscopy and colonoscopy findings were normal and a capsule endoscopy was performed. Capsule endoscopy showed a concentric, ulcerated and well-delineated stricture in the ileum, that hindered the capsule from progressing.
Figure 16 The capsule continued to transmit until the batteries expired, but spontaneous expulsion of the device was not observed.
Figure 17 A diagnosis was made of obscure-occult gastrointestinal bleeding due to an ulcerated ileal stricture. Elective surgical resection was planned.
Figure 18 Laparotomy was carried out, and a 23-cm segment of distal ileum, with the capsule inside, was resected.
Figure 19 Histological examination demonstrated several shallow ulcers in mucosa covered by scarce necrotic and granulation tissue, mucosal and submucosal edema, and intense vascular congestion.
Figure 20 There was a nonspecific inflammatory infiltrate with lymphocytes, plasma cells, neutrophils, and some eosinophils, all of which was consistent with an acute or subacute process induced by NSAID injury.
Case 5: Radiation enteritis
J. M. Herrerías, Á. Caunedo, J. Romero
Gastroenterology Service, ”Virgen Macarena“ University Hospital, Seville, Spain
Figure 21 A 60-year-old woman, who had been treated 10 years previously with surgery and brachytherapy for endometrial cancer, presented with iron-deficiency anemia and abdominal pain. Small-bowel follow-through, gastroscopy and colonoscopy were normal. Capsule endoscopy was performed. An abnormal villous pattern in prestenotic ileal mucosa was seen.
Figure 22 Bleeding (down) ileal stricture, which caused capsule retention could be seen.
Figure 23 The ileal stricture with an ulcer at its border.
Figure 24 On elective laparotomy, an edematous small-bowel loop with an ulcerated stricture, and the capsule, were identified.
Figure 25 Histological examination of the surgical specimen showed normal mucosa and thickened and fibrotic submucosa.
Figure 26 Thickened submucosa with signs of fibrosis and vessels with hyaline thickening. On the basis of the clinical, endoscopic, and histological data, a diagnosis of submucosal post-radiation fibrosis was established.
Case 6: Autoimmune enteropathy
M. Keuchel1, C. Thaler1, R. Höhne2, E. Arnold1, J. Caselitz2, F. Hagenmüller1
1 First Medical Department, Allgemeines Krankenhaus Altona, Hamburg, Germany
2 Department of Pathology, Allgemeines Krankenhaus Altona, Hamburg, Germany
Figure 27 a A 78-year-old man was admitted with severe intestinal bleeding under ASA medication. EGD and colonoscopy were normal. Villous atrophy from the proximal jejunum to the mid small bowel was diagnosed by VCE, with diffuse bleeding (not shown). Endomysial antibodies were negative; a gluten-free diet did not stop the bleeding. Prednisone was given for suspected autoimmune enteropathy and bleeding stopped immediately b Repeat VCE after 20 months, to exclude intestinal lymphoma, showed normal villi, while prednisone had been tapered to 2.5 mg/day.
Figure 28 a Corresponding push enteroscopy initially showed villous atrophy.
Figure 28 b Push enteroscopy showed restitution with prednisone treatment.
Figure 29 a Jejunal biopsy confirmed total villous atrophy, with (polyclonal) lymphocytic infiltrate in addition, similar to Marsh class IIIc in celiac disease (periodic acid-Schiff reagent (PAS) stain).
Figure 29 b Restitution following prednisone treatment (PAS stain).
M. Pennazio, M. D.
Gastroenterology Unit 2 · Department of Gastroenterology and Clinical Nutrition ·
S. Giovanni A.S. Hospital
Via Cavour 31 · 10123 Turin · Italy
Fax: 39-011-6333623 ·
Email: mpen60@yahoo.com
M. Pennazio, M. D.
Gastroenterology Unit 2 · Department of Gastroenterology and Clinical Nutrition ·
S. Giovanni A.S. Hospital
Via Cavour 31 · 10123 Turin · Italy
Fax: 39-011-6333623 ·
Email: mpen60@yahoo.com
Figure 1 Jejunal Crohn’s disease: an ulcerous lesion on a mucosal crest is seen, near to a reddish area showing villous denudation.
Figure 2 The same patient as in Figure 1, with an ulcer in the jejunum before treatment with infliximab.
Figure 3 The jejunal ulcer after infliximab treatment.
Figure 4 Ileocolonoscopy of the same patient showed an aphthous lesion in the neoterminal ileum.
Figure 5 A fissural ulcer in the proximal ileum.
Figure 6 The same patient with inflammatory stenosis. The capsule passed through, causing pain for about 20 minutes.
Figure 7 Ileal ulcerations highly suggestive of Crohn’s disease. The diagnosis was confirmed by ileal biopsies and perinuclear antineutrophil cytoplasmic antibody (P-ANCA) testing.
Figure 8 As Figure 7.
Figure 9 A 24-year-old man presented with abdominal pain, weight loss of 7 kg, fever, elevation of C-reactive protein and leucocyte levels, and iron-deficiency anemia. Esophagogastroduodenoscopy (EGD) and ileocolonoscopy were normal. Video capsule endoscopy (VCE) showed an aphthous ulcer of the proximal jejunum.
Figure 10 Fissural ulcer with surrounding inflammatory swelling, seen at VCE.
Figure 11 Mucosal edema with inflammatory stenosis. The distal ileum was normal. The capsule passed the small bowel without complications within 5 hours and 46 minutes.
Figure 12 An abdominal computed tomography (CT) scan showed a thickened jejunal loop (arrows). No stenosis was seen at enteroclysis.
Figure 13 Transabdominal ultrasonography in power Doppler mode demonstrated a thickened jejunal loop with hyperperfusion.
Figure 14 A jejunal biopsy taken at push-enteroscopy showed aphthous lesions (white arrows) and an epitheloid cell reaction (black arrow), consistent with Crohn’s disease (hematoxylin & eosin; × 10).
Figure 15 A 72-year-old woman with chronic use of NSAIDs presented with severe iron-deficiency anemia. Small-bowel follow-through, gastroscopy and colonoscopy findings were normal and a capsule endoscopy was performed. Capsule endoscopy showed a concentric, ulcerated and well-delineated stricture in the ileum, that hindered the capsule from progressing.
Figure 16 The capsule continued to transmit until the batteries expired, but spontaneous expulsion of the device was not observed.
Figure 17 A diagnosis was made of obscure-occult gastrointestinal bleeding due to an ulcerated ileal stricture. Elective surgical resection was planned.
Figure 18 Laparotomy was carried out, and a 23-cm segment of distal ileum, with the capsule inside, was resected.
Figure 19 Histological examination demonstrated several shallow ulcers in mucosa covered by scarce necrotic and granulation tissue, mucosal and submucosal edema, and intense vascular congestion.
Figure 20 There was a nonspecific inflammatory infiltrate with lymphocytes, plasma cells, neutrophils, and some eosinophils, all of which was consistent with an acute or subacute process induced by NSAID injury.
Figure 21 A 60-year-old woman, who had been treated 10 years previously with surgery and brachytherapy for endometrial cancer, presented with iron-deficiency anemia and abdominal pain. Small-bowel follow-through, gastroscopy and colonoscopy were normal. Capsule endoscopy was performed. An abnormal villous pattern in prestenotic ileal mucosa was seen.
Figure 22 Bleeding (down) ileal stricture, which caused capsule retention could be seen.
Figure 23 The ileal stricture with an ulcer at its border.
Figure 24 On elective laparotomy, an edematous small-bowel loop with an ulcerated stricture, and the capsule, were identified.
Figure 25 Histological examination of the surgical specimen showed normal mucosa and thickened and fibrotic submucosa.
Figure 26 Thickened submucosa with signs of fibrosis and vessels with hyaline thickening. On the basis of the clinical, endoscopic, and histological data, a diagnosis of submucosal post-radiation fibrosis was established.
Figure 27 a A 78-year-old man was admitted with severe intestinal bleeding under ASA medication. EGD and colonoscopy were normal. Villous atrophy from the proximal jejunum to the mid small bowel was diagnosed by VCE, with diffuse bleeding (not shown). Endomysial antibodies were negative; a gluten-free diet did not stop the bleeding. Prednisone was given for suspected autoimmune enteropathy and bleeding stopped immediately b Repeat VCE after 20 months, to exclude intestinal lymphoma, showed normal villi, while prednisone had been tapered to 2.5 mg/day.
Figure 28 a Corresponding push enteroscopy initially showed villous atrophy.
Figure 28 b Push enteroscopy showed restitution with prednisone treatment.
Figure 29 a Jejunal biopsy confirmed total villous atrophy, with (polyclonal) lymphocytic infiltrate in addition, similar to Marsh class IIIc in celiac disease (periodic acid-Schiff reagent (PAS) stain).
Figure 29 b Restitution following prednisone treatment (PAS stain).