title: Significant small-bowel lesions detected by alternative diagnostic modalities after negative capsule endoscopy.
abstract: 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.
  
  
  METHODS
  A retrospective case series.
  
  
  METHODS
  Single-center academic endoscopy unit in a tertiary-referral hospital.
  
  
  METHODS
  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.
  
  
  METHODS
  CE was performed in all patients. Further evaluation via DBE, CTE, or MRE was performed. Definitive treatment was carried out by enteroscopic polypectomy (1 patient), surgical resection (2 patients), and transjugular intrahepatic portosystemic shunt procedure and embolization (1 patient).
  
  
  METHODS
  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 stromal tumor). The fifth patient had a large PJS polyp in the proximal ileum.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Wolfson Unit for Endoscopy, St Mark's Hospital, London, UK.
authors.forename: Aymer
authors.initials: A
authors.lastname: Postgate
authors.forename: Edward
authors.initials: E
authors.lastname: Despott
authors.forename: David
authors.initials: D
authors.lastname: Burling
authors.forename: Arun
authors.initials: A
authors.lastname: Gupta
authors.forename: Robin
authors.initials: R
authors.lastname: Phillips
authors.forename: James
authors.initials: J
authors.lastname: O'Beirne
authors.forename: David
authors.initials: D
authors.lastname: Patch
authors.forename: Chris
authors.initials: C
authors.lastname: Fraser
mesh_terms: D000328:Adult; D000368:Aged; D053704:Capsule Endoscopy; D016099:Endoscopy, Gastrointestinal; D005188:False Negative Reactions; D005260:Female; D006801:Humans; D007410:Intestinal Diseases / Q000175:diagnosis*; D007421:Intestine, Small / Q000473:pathology*; D008279:Magnetic Resonance Imaging; D008297:Male; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed