Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy

Background: Capsule endoscopy (CE) is considered a first-line investigation for obscure GI bleeding (OGIB) and small-bowel polyp or tumor detection. The reliability of a negative CE in excluding gross small-bowel pathology remains Unclear. New imaging modalities, such as double-balloon enteroscopy (DBE), CT enterography (CTE) or magnetic resonance enterography (MRE) now provide complementary roles to CE for these indications. Objective: We describe our experience of significant small-bowel pathology missed at CE in 5 patients. The lesions were subsequently detected by DBE, CTE, or MRE. Design: A retrospective case series. Setting: Single-center academic endoscopy unit in a tertiary-referral hospital. Patients: Five patients were evaluated: 4 with a history of OGIB (transfusion dependent in 2) and 1 patient with Peutz-Jeghers syndrome (PJS) under small-bowel surveillance. Interventions: CE was performed in all patients. Further evaluation via DBE, CTE, or MRE was performed. Definitive treatment was carried out by enteroscopic polypectomy (I patient), surgical resection (2 patients), and transjugular intrahepatic portosystemic Shunt procedure and embolization (I patient). Main Outcome Measurements: Detection of significant small-bowel pathology by using DBE, CT, or MRE after a negative capsule study, Results: Significant small-bowel pathology was missed at CE but was detected by alternative modalities in 5 patients. In 4 patients, the lesions were in the proximal small bowel (adenocarcinoma, malignant melanoma, varices, and stormal tumor). The fifth patient had a large PJS polyp in the proximal ileum. Limitations: Retrospective case series with small numbers. Conclusions: Gross pathology may be missed at CE, especially in the proximal small bowel, and a negative CE Study does not exclude significant disease. Alternative imaging modalities, such as DBE, CTE, or MRE, should be considered when clinical suspicion persists.