A fatal outcome in a patient with coeliac disease who suspended a strict gluten-free diet: a case report

Coeliac disease (CD) is an autoimmune small bowel disease that occurs in susceptible individuals that develop an immunological reaction to gluten. A strict gluten-free diet (GFD) is the primary treatment for CD. This case report describes a patient with CD recurrence due to a discontinuation of a strict GFD by the patient. After recurrence, the patient developed fever and pancytopaenia, and quickly died of haemophagocytic lymphohistiocytosis (HLH). To the best of our knowledge, this is the first description of a case of CD associated with HLH due to discontinued GFD, which may contribute to improving the awareness of the importance of maintaining a strict GFD and having regular follow-up examinations.

Video capsule endoscopy: Initial experience from a tertiary care center in Sri Lanka

Background: Since its global introduction in 2000, capsule endoscopy (CE) has revolutionized the evaluation of small bowel disease. Aims and Objective: The aim of this study was to share our experience with CE including the findings and its diagnostic yield. Materials and Methods: A retrospective study was carried out at Colombo South Teaching Hospital of Sri Lanka. Data of patients who underwent CE from its initiation in 2017 until June 2020 were obtained from the hospital computer database. These included the patient demographics, indications for the study, quality of bowel preparation, and its findings. Results: The study included 54 patients with a mean age of 55 years. Mean gastric time and small bowel transit time were 52 and 272 min, respectively. Forty-five CE studies were done for the evaluation of small bowel bleeding and an abnormal study was found in 26 (57.78%) patients. Small intestinal ulcers and erosions were the most frequently found abnormality (n=16, 35.56%) followed by tumors (n=5, 11.11%). Active bleeding was evident in 14 (31.11%) patients. Overall diagnostic yield was higher in those with a history of overt bleeding (n=15, 71.43%) compared to occult bleeding (n=11, 45.83%). Most patients who were evaluated for abdominal pain and diarrhea had normal CE except for two who had small intestinal ulcers and subepithelial lesions. Only one case was complicated with capsule retention. Conclusion: CE is a useful investigation for the evaluation of small bowel disease, particularly in suspected small bowel bleeding. In contrast to western population, ulcers and erosions were the more frequently found abnormalities seen in local setting.

P158 Diagnostic yield of different imaging modalities (VCE, MRE and SBUS) in paediatric Inflammatory Bowel Disease patients

Background Wireless Video Capsule Endoscopy (VCE), Magnetic resonance enterography (MRE) and Small Bowel ultrasound (SBUS) are well-established diagnostic tools, used in the evaluation of small bowel disease in paediatric inflammatory bowel disease (IBD) patients.The aim of this study was to compare VCE findings with those of MRE and SBUS and evaluate discrepancies between them. Methods VCE examinations were conducted in histologically confirmed paediatric IBD patients in a period of 19 months (March 2018 – November 2019) in a tertiary center. The VCE findings were retrospectively compared to relevant findings on MRE and SBUS, collected from electronic data records. Results 34 patients were included in the study (16 males,18 females) with an age range at the moment of diagnostic assessment between 4–17 years (median 12 years). 21 patients were diagnosed with Crohn disease (CD), 9 patients with Ulcerative Colitis (UC) and 4 patients with IBD Unclassified (IBD-U). 8/34 (23.5%) patients were found to have all three diagnostic investigations, 21/34 (61.8%) had MRE and 21/34 (61.8%) had SBUS. Concordance between the three modalities were seen in 5/8 (62.5%) patients. Of these, 3/5 (60%) had no small bowel disease identified on VCE, MRE and SBUS, while in 2/5 patients (40%) the same distribution of small bowel disease was identified using all three diagnostic modalities. When comparing VCE to MRE, differing distributions of disease were seen in 10/21 patients (47.6%). 6/10 (60%) had terminal ileitis, 2/10 (20%) had ceacal disease and 3/10 (30%) jejunal disease noted on MRE, but with no disease identified on VCE. 1/10 patient (10%) had a normal MRE but duodenal and proximal jejunal ulceration was reported on VCE. VCE and SBUS had a higher concordance (71.4%) in identifying disease distribution. In 6/21 patients (28.5%) there was a discrepancy in the findings reported on SBUS when compared to VCE.Of these, 4/6 (66.7%) had a normal SBUS but small bowel disease (jejunal and ileal disease) on VCE.1/6 patient (16.7%) had caecal inflammation and 1/6 (16.7%) had active terminal ileitis on SBUS, which was not reported on their VCE. Conclusion The identification of small bowel disease is essential in the diagnosis and subsequent management of paediatric IBD. VCE, MRE and SBUS are established modalities to detect intestinal disease. This study demonstrates that performing all three diagnostic modalities may have important practical significance and increase diagnostic yield in detecting small bowel inflammatory bowel disease.

Diagnosis and therapy using double-balloon endoscopy for small bowel disease: experience from a Chinese tertiary hospital

Objective To evaluate the clinical efficacy of double-balloon endoscopy (DBE) for small bowel disease (SBD). Methods The clinical and endoscopic data of patients who underwent DBE in a Chinese tertiary hospital from January 2006 to December 2019 were retrospectively reviewed. The patients were divided into three groups by age: the young group (<45 years), middle-aged group (45–65 years), and older group (>65 years). Results In total, 1177 patients who underwent 2134 DBE procedures were included. The anterograde and retrograde route was used in 1111 and 1023 procedures, respectively. The most common reason for performing DBE was suspected small bowel bleeding (SSBB) (53.1%), and the most common SBD was Crohn's disease (CD) (18.1%). Hemostasis was the predominant endoscopic therapy (54.3%). The total complication rate was 0.8%. The incidence of CD was highest in the young group, and the incidence of tumors was highest in the older group; these findings were consistent both among the overall patient population and among patients with SSBB. Conclusions DBE is effective and safe for the diagnosis and treatment of SBD and is considered to have great potential as a first-line method for diagnosing SBD.

Panenteric capsule endoscopy identifies proximal small bowel disease guiding upstaging and treatment intensification in Crohn’s disease: A European multicentre observational cohort study

Background Endoscopically defined mucosal healing in Crohn’s disease is associated with improved outcomes. Panenteric capsule endoscopy enables a single non-invasive assessment of small and large bowel mucosal inflammation. Aims and methods: This multicentre observational study of patients with suspected and established Crohn’s disease examined the feasibility, safety and impact on patient outcomes of panenteric capsule endoscopy in routine clinical practice. The potential role in assessment of disease severity and extent by a comparison with existing clinical and biochemical markers is examined. Results Panenteric capsule endoscopy was performed on 93 patients (71 with established and 22 with suspected Crohn’s disease). A complete examination occurred in 85% (79/93). Two cases (2.8%) of capsule retention occurred in patients with established Crohn’s disease. Panenteric capsule resulted in management change in 38.7% (36/93) patients, including 64.6% (32/48) of those with an established diagnosis whose disease was active, and all three patients with newly diagnosed Crohn’s disease. Montreal classification was upstaged in 33.8% of patients with established Crohn’s disease and mucosal healing was demonstrated in 15.5%. Proximal small bowel disease upstaged disease in 12.7% and predicted escalation of therapy (odds ratio 40.3, 95% confidence interval 3.6–450.2). Raised C-reactive protein and faecal calprotectin were poorly sensitive in detecting active disease (0.48 and 0.59 respectively). Conclusions Panenteric capsule endoscopy was feasible in routine practice and the ability to detect proximal small bowel disease may allow better estimation of prognosis and guide treatment intensification. Panenteric capsule endoscopy may be a suitable non-invasive endoscopic investigation in determining disease activity and supporting management decisions.

A151 ASSESSMENT OF CAPSULE ENDOSCOPY UTILIZING CAPSOCAM PLUS® IN PATIENTS WITH SUSPECTED SMALL BOWEL DISEASE INCLUDING PILOT STUDY WITH REMOTE ACCESS PATIENTS

Background Capsule endoscopy (CE) has been widely utilized for the assessment of patients with known/suspected small bowel disease. The CapsoCam Plus® capsule is unique in that it utilizes four cameras at sequential 90 degree intervals in its mid-section permitting a 360-degree panoramic perspective with a 15+ hour battery life. A panoramic view has been suggested to improve overall visualization of the small bowel (SB) therefore potentially improving diagnostic yield. Unlike other small bowel capsules, it must be retrieved upon excretion (utilizing a magnetic kit) since the images are stored on the device. Aims To assess the use of CapsoCam Plus in patients referred for suspected small bowel disease, including pilot assessments for patients in remote locations. Methods A retrospective chart review (01/16 – 09/19) assessing consecutive capsule procedures utilizing this device was performed. Information acquired included basic demographics, indication, extent of examination, gastric transit time, small bowel transit time, yield, adverse events, capsule retention, recovery rates and recommendations for follow up. A pilot study was also initiated for patients in rural centers to access capsule testing remotely through mail courier without attendance/travel to the primary dispensing site. Results Acquired data included 63 patients receiving CapsoCam Plus®. Indications: 32% obscure gastrointestinal bleeding, 52% iron deficiency anemia, 2% abdominal pain and 6% for IBD. 92% of studies were completed to cecal visualization. Mean gastric and small bowel transit time were 0:48:17 and 3:54:29. 94% were retrieved using retrieval kits provided to patients. 2% retrieved endoscopically from the stomach (retained due to pyloric stenosis), 2% retained in terminal ileum (previously undiagnosed stricture) and 2% not retrieved due to failure of patient to use retrieval kit. 73% of studies were normal SB, 13% contained SB ulceration/erosive disease and 8% did not demonstrate the entire small bowel. Recommendations for follow up included supportive therapy (47%), more aggressive iron supplementation (1%), repeat capsules (19%) and 14% for routine office follow up and discussion. All three capsules mailed to patients in remote communities were completed successfully. Conclusions CapsoCam Plus® had a high retrieval rate of 97% demonstrating that with appropriate patient selection, recovery rates are very high. Only 3% of patients had retained capsules. Most patients in this study had a normal small bowel, however; images and completion rates were adequate to assess small bowel in the vast majority of patients. Success was obtained with mailing this capsule to remote sites sparing the patient travel to the dispensing site. Funding Agencies None