Small Bowel Post Endoscopy Approach

Small Bowel Post Endoscopy Approach

Speaker one:

Uh, and we don't consider the the frequencies, um, frequency events, uh, measured to standard rate of, of, of the CMS. Today, uh, I'll be talking about, uh, context to special text to API agreement, uh, some time. Today I'll be talking on an unusual talk, how to approach post-model analysis. Like, many times we would have heard, like, uh, endoscopy is normal, colonoscopy is normal. Get patient is having symptoms. What to do with these patients? We may not know. So it can be a small world. These are the indice patients. These are the endoscopy and colonoscopy are normal. So today's, uh, focus is on how to approach these images, approach to situations with small volume surface. So when small intestine really is not really small, it's actually a really long, uh, it is almost five to seven meters in length, uh, it is it has lots of small, small. But by the name is because of the diameter. Large intestine is almost five to seven centimeters, while small intestine is almost three centimeters. Coming to a small recap on physiology of dilation. So after eating food, uh, carbohydrates by salivary analysis, they get converted into polysaccharides. When these polysaccharides from pancreas juices get converted into maltose disaccharides, and from, uh, at the level of intestinal villa, the epithelium, these, uh, disaccharides are converted into monosaccharides. Protein in the stomach, uh, proteins by pepsin, by gastric pepsin, they get converted into polypeptides, and at the level of intestine epithelium, they get converted into small peptides, and amino acids where they are subsequently absorbed. And fat digestion, fat globules, Listen, and they get, uh, uh, uh, they become further small. They get converted into dry grasslands, protein-coating dry tile microns, and then from there into the lymphatic venous system. And also protein absorption happens. In simple terminology, explain digestion system means the process which starts with the right hand and ends with the left hand.

Speaker two: Yes.

Speaker one:

Joe's, Joe's a Catholic. Catholic is geology, like, uh, they are so many liminal core factors and mucosal factors which cause small intestinal, uh, bowel disorders. So what happens at the level of the, in the, in the inside the, uh, small bowel lumen? So there can be small bowel overgrowth. There can be filament Uh, no, it's a basin activity in India, tropical streams, and small industrial factory overflow. So there is a concern, right? There is a rise in grants, last month we had the world IBDA IBDA, so they are very, uh, multiple factors why IBD is rising in India. Grants in two thousand, in two thousand, the instance was only four point three percent, now the instance is almost twenty-two percent, that is a rapid rise, maybe because of Westernized diet, urbanization, antibiotic overuse, and also hygiene advertises. The other things are less important because small industry has dimension inflammation, grants, celiac, SIBO, it can be obstruction because of structures, tumors, and the other part is bleeding, maybe because of bleeding for illusion ulcers and microscopy. Clinical features. So whenever a patient has anemia, central abdominal pain, diarrhea, this abdominal distension and emaciation, think of small bowel disease. So this is a small histology image showing normal will and damaged will, so when small bowel, uh, small intestinal will are damaged, there is no absorption, then they'll have malabsorption, they can have flatulence, diarrhea, spiritualia, weight loss, anemia, hypodeficiencies. So what is flatulence? This is a principle water, which happens the greatest picture pass, contains very bad smell, that is because of hydrogen sulfide, diethyl sulfide, or methanol. Spiritualia, these patients, because of malabsorption, can have spiritualia. Classically described as bulky, voluminous foods, which are made of very healthy, uh, gray-colored, yellowish, they are greasy or oily in appearance, foul-smelling with bulky portion. Clinical features, the most common symptom is diarrhea, patients especially have chronic diarrhea, sometimes we have enthusiastic patients, they'll be telling, "I know every toilet on the road from Kuala Lumpur to Chennai will be straightly with them because they usually suffer a lot because of frequent, uh, frequent use foods." When we take history, we need to know whether it is a pathology in the small bowel or large bowel. There are some important factors. For example, the reaction. The presence was with greasy stools, excessive flatulence, protein malabsorption, even edema, pain, foul-smelling stools, with the vitamin deficiency can be a cause of small intestinal disorder. So we should, uh, take proper history in these patients. For example, this is a cut surface of the intestinal lumen, we have all the layers. In the post mucosa, submucosa, muscle layer, and the xylosa. So what are the functions of each layer? Mucosa, we know, it is important for absorption, secretion, and diarrhea difference, because, uh, when this is altered, when there is mucosal defect or mucosal ulcers, uh, they can develop diarrhea, malabsorption, bleeding, anemia, nutritional deficiencies, and weight loss. This can happen in celiac or early IBD. When submucosa is involved, which contains more of lymphatics and blood vessels, there can be overt bleeding, and hypoalbuminemia or edema. Then muscle layer is involved, there can be colicky pain, vomiting, distension, and they can present with strictures, obstruction, and when the outermost layer, xylosa, is involved, there are fistula, abscess, perforation, which can be seen in the retrograde or advanced growth stages. So when we are seeing these patients, we should, uh, take some time to do physical examination, because there are so many signs. For example, vitamin B complex, B twelve deficiency, vitamin C, or folate deficiency can cause all these glossitis, chelosis, or amyloid stomatitis. Vitamin A can cause night blindness, xerophthalmia, follicular keratosis, or bite of spots, they can be ecchymosis, easy bruisability, and there is vitamin K and vitamin C deficiency. Vitamin D can cause osteopenia and osteoporosis. Vitamin E deficiency can cause ataxia, neurological symptoms. And there are various neurological symptoms which patients can present, these are all, especially we see more of B twelve deficiencies, when they have malabsorption, they can have peripheral neuropathy, myelopathy, and vitamin E can cause ataxia, and all this. So frank nutrient deficiency is not very common, but subtle signs we should never miss them in our patients. We should, when we are doing general examination, we should look for clinical clues, they can be white dot spots because of vitamin A deficiency. This is episcleritis in a patient of IBD, then they can be glossitis, amyloid stomatitis, oral ulcerations, lymphadenopathy, cutaneous, they can be follicular hyperkeratosis because of vitamin A deficiency, this is called as well dermatitis, herpetoconus, which can, which we don't see over here, but can be seen in patients with celiac, nail changes like oleonychia, either edema, because of protein loss, vitamin B deficiency can cause bone changes, osteopenia, and ataxia, and there is vitamin E deficiency, and B twelve can cause peripheral bleeding. So all these are very important, so before coming to a diagnosis for these patients, uh, rarely we can diagnose small bowel disorders with only single test. We should get clues from history, examination, laboratory evidence, imaging, and endoscopy. All this is very important. So how to diagnose these, uh, these individuals with small bowel problem? There are tests to assess the small intestine function, they are called as functional tests, and tests to assess small intestinal structure. Imaging and endoscopy. When doing functional test, these are all, everything is very, very useful in these patients, especially B twelve, fecal analysis, stool for fatty acids, all that will be helpful. Whether there is any inflammation, CRP, fecal calprotectin, when there are simple blood tests which are available. And to assess structure, we can do radiological investigations, or endoscopic evaluation. Before we, uh, we, uh, diagnose these patients, we should do some, some tests at least. Uh, how many general medicine degrees are here? So there are some clues, like when we do, they can be, uh, uh, they can be anemia, this is a reference we are showing microcytic hyperpigmented anemia, this is a small, they compare with the lymphocytes, this is smaller than, uh, this is smaller than a lymphocyte, this is an early B twelve deficiency which causes hyperpigmented neutrophils, and the lymphocytes and the, uh, this is almost the same, same size. And this is a test of neuroplastic anemia, now the lymphocytes are very small, this is available. So all this is important, stool, uh, inspection is also important, and fecal calc analysis can be useful, but readiness is we should ask for the, you know, special same modified icon stain for we should ask for the acid, uh, modified acid stain for microscope area. We should ask for the modified icon stain. So always request for special staining for this. This is a histology bench which was small, uh, uh, proposals of relation with the malabs option, and this is in a immunocompromised individual, isospora. It is special staining. Protecting is an excellent test, but, uh, somehow it is underutilized.

That's what, uh, we feel. This is a simple non-invasive test. It's a marker of, uh, intestinal inflammation. So calprotectin is there in the macrophages, and when there is excess inflammation, this, uh, calprotectin can be, uh, uh, measured in the, uh, spoon sample. And it is especially useful when we are, uh, dealing with the case of IBD to monitor the disease individuals and whether it is for organic or functional disorder. Also it can, uh, guide us. Whenever people have protectin is less than one hundred, we do not worry, but more than one hundred or even thousands, we have to do further tests for patients, especially if we are suspecting IBD. It can be a case of IBD. The specific test for confirming malabs option. This is a very simple test. We will not need xylose. Just give them twenty-five grams of xylose orally, and try to collect the urine sample over five hours. If the xylose is not absorbed, the value will be less than the urine, and it assesses malabs option. Uh, but it can only tell whether there is malabs option or not. It cannot diagnose what is the cause for malabs option. Cause for malabs option, we need the tissue diagnosis sometimes. Simple breath test like, uh, uh, we have tests available for carbohydrate malabs option, but unfortunately we don't have tests for fat or protein malabs option because these are very expensive, and they are only for research, uh, uh, setting. Principal for this breath test is just, uh, the intestinal bacteria can metabolize carbohydrate substrates producing hydrogen or methane, and this can be measured by the breath. So just give them carbohydrate oral sugar, and try to do a breath test. If any value more than twenty parts per million, it can be a case of malabs option. So as I mentioned, these are very simple tests, non-invasive and easy to use. Any value more than twenty parts per million is diagnostic of, uh, malabs option. So when we are using glucose, which with one hundred grams, that was fifty grams. Lactulose and fructose we want to test. We can test the, uh, so at our unit we use wet form from USA. In the between suspect lactose intolerance, just give, uh, fifty gram of lactose powder, and if the value is more than twenty, it means there's, uh, lactose, uh, malabs option. The specific test for, uh, cycles small intestinal bacterial overflow. We prefer to use glucose because lactulose, even though it is a good test, it can increase the, uh, uh, colonic transit. Intestinal transit. So, uh, glucose is much, uh, more preferred. So this is a normal glucose breath test, and in case there's malabs option, there can be a rise in, uh, hydrogen in the breath. As shown in this diagram. For lactulose, we can see we can this is a, uh, a test result showing double peak. When small intestine bacteria are more, the, uh, uh, lactulose is converted into hydrogen. This is showing the intestinal part, and this is showing the colonic part. So in any patient when they are having low intense symptoms of bloating, abdominal pain, altered bowel habits, think of SIBO, and you can do a small breath test if it is positive. Just for attachment for solar attachment for five milligrams twice daily. For minimum fourteen days, it will help these patients. To assist the structure of the small bowel, we have we can do imaging. Uh, radiology, capsule endoscopy, and microscopy. Radiology, we have N number of tests, but each has its advantages and disadvantages. You can do a brain X-ray. Here there's a, uh, dilated bowel moves in the brain X-ray. You can these we were doing earlier small bowel follow-through, intestinal ultrasound very good for, uh, follow-up of the patients with diabetes. We can do CT endography or we can put a massive gastric loop and do CT

endoplasis and if patients with the osteogenetic we can, uh, if we don't know where is the cause for bleeding, we can do a RBC tax or angiogram. All these are helping patients but there is a challenge, uh, especially small bowel image can be challenging why this happens is when we are doing ultrasound like the entire colon the lumen of the small bowel can have gas and this happens in ultrasound. Lumen of the small bowel is usually collapsed. So even if we need to do contrast, we need to do a large volume of contrast and the. Sometimes if there's a pathology over here, it becomes difficult when you when doing the CT endography whether the pathology is right in this segment or in the adjacent segment. That becomes challenging sometimes. So that's .

kept them in a submarine, and they injected into a human body. This is a world movie, science fiction movie. They are from outside, they are in the submarine, it's going to the IV line, and from outside it is going like we will have this scene, where they are exactly they want to go inside and create an image of. And these are all the IVCs. All these scientists are amazed to see all these visuals. And people thought this is only a science fiction movie, can this happen in real life? But to our surprise, capsule endoscopy came. Any idea how this capsule endoscopy came into medical field? Well, during lockdown I was living this book called Startup Nation, and I was surprised to see something about medical technology written in this book. So this is the person, he's called as he's not a doctor, he's a rocket scientist for Israel Defense Forces. He specialized in electro-optical devices. He had a novel idea how we can use missile technology, we can put this camera into a vein which can transmit pictures, no one encouraged him, but he had perseverance, he persisted and succeeded. Then in two thousand one, two camp was first time introduced in the world. So this is a old picture, late Jayaleka, and Dr. Vijiman Prasad, subsequently they were the first people to launch capsule endoscopy in the world. There is GBSERV. So this is an example of technological transfer, like optics, electronics, ample of technological transfer, like optics, electronics, Good abdominal pain, bronchitis, and multiple ulcers. There can be small ulcers; stenotic septum potential ulcers can cause strictures later on. And ulcerative stenosis. All this can be diagnosed by capsule endoscopy. Comparing the capsule endoscopy, this is an excellent investigation. It outperformed MR and intraoperatively. And it detects more small bowel lesions than CT intraoperatively as well, you see. And it can identify effectively the bleeding sources in patients with extra-GI bleed. We will start capsule endoscopy; it's a very good technology, but some of only we can see the we can only visually diagnose the patients, but we cannot actually take a biopsy. So now new technology is getting incorporated into capsules; we don't know if it's very interesting. This is a magnetic capsule. We are trying to manipulate from the outside; they're trying to take it left and right. For technology. So for Apache and Zardas, we have invested in lower GMV at the wellness level. We need more sophisticated technology especially for evaluation of the small power. Because even though push entrance copy video capsule entrance copy are available, they have some limitations. Push entrance copy to some extent we consider small one, but entire small one will not be able to evaluate. It is a very big investor push to entrance copy. This is a very senior gastroenterologist performing push entrance copy. So even though multiple attempts he's trying to push into the enteroscope, it's a long it takes time-consuming procedure. Why this with routine electron CM images are shown and when they are taking too much of time the technician everyone gets annoyed. When is this person going to leave me there within me? Despite so many attempts, they're not able to advance push entrance code. I just show the CM image. So what happens over here is this is the inverse of fixed field inverse of. Even though we use so much of force just doesn't give transmitted to the tip of the inverse code. So whatever he's trying to push or pull because of the small power nomenclature it has a tendency of loop. That's why it doesn't advance. So this is a difficulty. So subsequently to put it into the deeper small power and they came with something called a deep entrance copy. So they attach a small wire to the tip of the entrance code or a manual stylus or motorized entrance copy. Then with this technology we are able to see more part of the small intestine. So the same long entrance code will get a small balloon and this will help to clean the small intestine. So they are the single balloon entrance copy and small balloon entrance copy is now available. Then came how about putting something like articular tip of the entrance copy? So what is this cleaning? Same like for pile jam of the clothes and just show this video. Only if we push it will not go the thread. So we need to put some either a pen or something at the tip of the rope. So after doing that we'll be able to clean it and we'll be able to go further. The same technology. They kept a motorized stylus at the tip of the entrance code. And after doing that within minutes we can go inside and we can actually evaluate the entire small power unit. So this is a very good technology. It was available earlier. Now it is undergoing some modifications. So what happens is this is a regular endoscope and there is a small stylus with the tip of the endoscope. And within minutes we'll be able to go into the deeper parts of the small intestine. And the main advantage is we can see the lesions and actually we can treat the lesions while doing the procedure itself. So we launched this technology in twenty twenty. We can use lots of accessories while doing the procedure. There is a polyp we can remove. There is a bleeding area we can actually treat for regularly. So multiple therapeutic applications of stylus entrance copy. This is our publication in video GI series. There we could reach target lesions in most of the patients using stylus entrance copy. So before I close a few case scenarios. This is we had a sixty-four-year-old male patient which presented with different abdominal pain and vomiting. CT and probably showed large segment circumferential wall thickening. Involving the proximal ileum. So we did stylus endoscopy and colonoscopy were normal. We did stylus enteroscopy and we saw these are circumferential ulcerated areas in the small bowel. And we took biopsy and it turned out to be a case of pancreasis. Later on after treatment he was doing very well. This is another case who presented with a HP of liquid in shock. Hemoglobin was less than one. We thought he will not survive. Somehow we could save this individual. After multiple transfusions we stabilized his hemoglobin. And colonoscopy showed endoscopy was normal. Colonoscopy lots of altered blood inside the large bowel. So we did CT and probably in this patient which showed wall thickening involving the internal loops. So we went ahead and did stylus enteroscopy. We are doing deep enteroscopy using the stylus tube. And at the distal junction of we could see a large ulcerated area and this first was in bleeding. So we did a dual therapy. We did injected epinephrine and then we clipped the lesion. And at the end we sprayed collagen which is a hemostatic powder. And this patient was doing very well. He's on follow-up with us for pancreasis and he's doing very well. The stabilized and later on discharged. So this is an interesting finding when we were doing the stylus enteroscopy. As we are advancing further we got confused. There are two lumens. Should we enter right or we don't know. It's a patient with massive lower GI bleeding. It's a patient with Mickels diverticum. The right side we could see the diverticum. And our subsequently we posted the procedure. Future perspectives. Well endoscopy is involving in a very big way. Now I have a robotic endoscopy is coming in a big way. When motorized capsule endoscopies are getting available now their number is such long. This is something called NPTAGs. What they do is it goes inside your stomach. It's like a moving they can actually like how we used to play video game. We can actually navigate capsule inside the human being. This is like a torpedo. How they are propulsion devices at the end. Using a simple remote we can actually manipulate the capsule. And future is very interesting. Now there's something called a slang robot. Future this may become available in medical technology. If someone scholars doctor graduate by mistake this slang robot tuning them we can build. It will just go inside and help in that way. And without doing any procedure patient can get discharged. So this is very interesting. And who knows later on they might develop a small robot like this like a spider like this which can be kept into a capsule. So a patient has abdominal pain. Just give this capsule. Robot will go inside. It will keep searching what is happening inside. So here there's a perforation. So immediately it sees and it starts seeing everything. All this may not be available now but maybe it available in the future. Before I close so there are so many small bowel disorders like inflammatory Crohn's. Malabsorption syndromes. All these are there. So to diagnose this small intestinal disorder it is we need to do more tests. One test may not be clear enough. Peripheral history clinical examination provides first two to localize and proceed for further evaluation in these patients. Combination of tests like functional assessment and structural evaluation is required. Every unexplained anemia or chronic area weight loss or obscure GI bleeding. This has a journey to the small bowel. Thank you very much.