Suspected Small Bowel Tumors: Differentiating Bulges from Masses
by Marco Pennazio, MD
Division of Gastroenterology, S. Giovanni A.S. Hospital, Turin, Italy
Editor: What have you seen in your practice of CE over the last few years that has surprised you or changed your thinking?
I use video
Dr Pennazio: I was surprised by discovering a lot of tumors. Today we the PillCam capsule in patients with iron deficiency anemia, young patients in whom the prevalence of tumors is substantial. With the use of this tool, we can anticipate diagnosis, and we may also influence outcome.
What is a bulge?
A bulge is a round, smooth, large base protrusion in the lumen having an ill-defined edge on the surrounding mucosa. It may be a prominent normal fold; loop of bowel overlying the loop being inspected (ie, an extrinsic compression); or the luminal expression of intestinal loop angulations and stiffness.
Differentiating bulges from masses is a multistep process
1. Identification: Look for an area that is abnormal or different from other areas; locations where the video capsule stops or slows may also be a clue to an underlying abnormality, possible presence of pathology.
2. Interpretation: Consider whether the abnormality in the CE image is clinically significant. Correlate CE images with patient’s clinical history. Always use Capsule Endoscopy Structured Terminology (CEST). See additional tips below for interpreting CE images.
3. Localization: Use Localization software. Note transit times. Observe mucosal patterns.
4. Management: CE findings should be cautiously interpreted in the light of clinical history before the decision is made to go to surgery.
Additional tips for interpreting CE images
Visual clues for a bulge
• Abnormality that moves with peristalsis, indicating its softness.
Hint: Use the mouse with a jogwheel for viewing certain image sequences repeatedly.
Visual clues for a submucosal process
• Alert signs:
o Presence of bridging folds
o Stretching of the mucosa
o Mucosal edema
o Translucent mucosa
• Further signs indicating pathology:
o Persistence of the suspect image in a series of frames— be careful with single frame abnormalities
o Synchronous lesions
o Appearance of a more congested color than the surrounding mucosa
o Ulceration of otherwise normal-appearing mucosa
o Ulceration on summit of an abnormality
o Inverted folds—can also be an indirect sign of pathology
• Signs suggesting malignancy (when an image shows pathology):
o Obstruction of the lumen
o Thickening and infiltration of the plicae
o Bleeding ulcers
What can be of help?
• Correlating CE images with patient’s clinical history
• CE atlases, eg, RAPID® and Image Atlas on www.capsuleendoscopy.org
• Noninvasive complementary tests (US/CT/MRI)
• Repeat CE
• Invasive complementary tests (PE/ DBE)
• Consulting with colleagues and Capsule Clubs via www.capsuleendoscopy.org
• Courses run by professional societies
• Although reading CE studies for the presence or absence of tumors, particularly submucosal masses, can be difficult, the [PillCam] technology seems to be superior to any other methods.
• Although visualization is different with CE, experience gained through standard endoscopy is invaluable to the identification and interpretation of the abnormalities.
• There are visual clues that help differentiating bulges from masses.
• Images should always be interpreted in the light of the clinical history.
• Correct interpretation directly guides subsequent patient management.
This Clinical Topic was originally published in GI insider Vol. 5 No. 1 2007.