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Invited Commentary

Department of Radiology, Indiana University Hospital, Indianapolis, Indiana

View larger version (82K): [in a new window]   Figure 1.  Photograph shows the M2A patency capsule from Given Imaging. This obstruction pill is made of lactose and contains 100 mg of barium sulfate. It has dimensions similar to those of the wireless capsule and is biodegradable (100 hours).

View larger version (91K): [in a new window]   Figure 2a.  Early Crohn disease in a 35-year-old woman with unexplained abdominal pain and anemia who was referred for wireless capsule endoscopy. Results from a small bowel follow-through study, abdominal CT, and endoscopic examination of the upper and lower gastrointestinal tract were unremarkable. (a) Wireless capsule endoscopic image shows mucosal ulceration (arrows) partly encircling the lumen of the jejunum. (b) Double-contrast barium enteroclysis image of the proximal and middle jejunum obtained with methylcellulose shows neither evidence of ulceration nor fold thickening. The rest of the small bowel was also normal. The patient responded to medical treatment.

View larger version (147K): [in a new window]   Figure 2b.  Early Crohn disease in a 35-year-old woman with unexplained abdominal pain and anemia who was referred for wireless capsule endoscopy. Results from a small bowel follow-through study, abdominal CT, and endoscopic examination of the upper and lower gastrointestinal tract were unremarkable. (a) Wireless capsule endoscopic image shows mucosal ulceration (arrows) partly encircling the lumen of the jejunum. (b) Double-contrast barium enteroclysis image of the proximal and middle jejunum obtained with methylcellulose shows neither evidence of ulceration nor fold thickening. The rest of the small bowel was also normal. The patient responded to medical treatment.

View larger version (126K): [in a new window]   Figure 3a.  Early Crohn disease in a 54-year-old woman with unexplained abdominal pain, nausea, and vomiting and occasional diarrhea. Results from a small bowel follow-through study were unremarkable. Colonoscopy showed inflammatory changes at the transverse colon, and biopsy revealed lymphocytic colitis. (a) Axial CT enteroclysis image obtained at the level of the kidneys with water and intravenous contrast material shows thickening and increased mural enhancement of a segment of the transverse colon (arrow). Note the normal middle and distal ileal loops. C = ascending colon. (b) Coronal CT enteroclysis image shows increased paracolic vascular flow (hyperemia) in addition to the mural inflammatory findings. The small bowel appears normal. (c) Double-contrast air-barium enteroclysis image obtained 1 week after wireless capsule endoscopy shows scattered punctate and linear mucosal ulcerations (arrow) involving a long segment of the midileum, findings that are consistent with aphthae in early Crohn disease. The distal and terminal ileum are uninvolved. C = cecum.

View larger version (159K): [in a new window]   Figure 3b.  Early Crohn disease in a 54-year-old woman with unexplained abdominal pain, nausea, and vomiting and occasional diarrhea. Results from a small bowel follow-through study were unremarkable. Colonoscopy showed inflammatory changes at the transverse colon, and biopsy revealed lymphocytic colitis. (a) Axial CT enteroclysis image obtained at the level of the kidneys with water and intravenous contrast material shows thickening and increased mural enhancement of a segment of the transverse colon (arrow). Note the normal middle and distal ileal loops. C = ascending colon. (b) Coronal CT enteroclysis image shows increased paracolic vascular flow (hyperemia) in addition to the mural inflammatory findings. The small bowel appears normal. (c) Double-contrast air-barium enteroclysis image obtained 1 week after wireless capsule endoscopy shows scattered punctate and linear mucosal ulcerations (arrow) involving a long segment of the midileum, findings that are consistent with aphthae in early Crohn disease. The distal and terminal ileum are uninvolved. C = cecum.

View larger version (167K): [in a new window]   Figure 3c.  Early Crohn disease in a 54-year-old woman with unexplained abdominal pain, nausea, and vomiting and occasional diarrhea. Results from a small bowel follow-through study were unremarkable. Colonoscopy showed inflammatory changes at the transverse colon, and biopsy revealed lymphocytic colitis. (a) Axial CT enteroclysis image obtained at the level of the kidneys with water and intravenous contrast material shows thickening and increased mural enhancement of a segment of the transverse colon (arrow). Note the normal middle and distal ileal loops. C = ascending colon. (b) Coronal CT enteroclysis image shows increased paracolic vascular flow (hyperemia) in addition to the mural inflammatory findings. The small bowel appears normal. (c) Double-contrast air-barium enteroclysis image obtained 1 week after wireless capsule endoscopy shows scattered punctate and linear mucosal ulcerations (arrow) involving a long segment of the midileum, findings that are consistent with aphthae in early Crohn disease. The distal and terminal ileum are uninvolved. C = cecum.

View larger version (101K): [in a new window]   Figure 4a.  Diaphragm disease in a 69-year-old man who was referred for wireless capsule endoscopy because of unexplained gastrointestinal bleeding, negative barium and CT examinations, and unremarkable endoscopic findings in the upper and lower gastrointestinal tract. (a) Wireless capsule endoscopic image obtained at the level of the distal small bowel show a circumferential linear ulcer (arrow) and mild luminal narrowing. Double-contrast air-barium enteroclysis was requested to characterize ulcerations and the extent of possible stenosing Crohn disease obstructing the wireless capsule. (b) Double-contrast air-barium enteroclysis image shows focal circumferential fold thickening (arrow) obstructing the capsule. Multiple areas of proximal narrowing that did not obstruct the capsule were also seen in the midileum. Findings at surgery confirmed the radiologic diagnosis of diaphragm disease from long-term use of "baby aspirin" (81 mg of acetylsalicylic acid).

View larger version (134K): [in a new window]   Figure 4b.  Diaphragm disease in a 69-year-old man who was referred for wireless capsule endoscopy because of unexplained gastrointestinal bleeding, negative barium and CT examinations, and unremarkable endoscopic findings in the upper and lower gastrointestinal tract. (a) Wireless capsule endoscopic image obtained at the level of the distal small bowel show a circumferential linear ulcer (arrow) and mild luminal narrowing. Double-contrast air-barium enteroclysis was requested to characterize ulcerations and the extent of possible stenosing Crohn disease obstructing the wireless capsule. (b) Double-contrast air-barium enteroclysis image shows focal circumferential fold thickening (arrow) obstructing the capsule. Multiple areas of proximal narrowing that did not obstruct the capsule were also seen in the midileum. Findings at surgery confirmed the radiologic diagnosis of diaphragm disease from long-term use of "baby aspirin" (81 mg of acetylsalicylic acid).

View larger version (164K): [in a new window]   Figure 5.  Early Crohn disease in a 35-year-old woman with anemia and chronic diarrhea. Double-contrast air-barium enteroclysis image obtained prior to capsule endoscopy shows scattered linear ulcerations in the midileum (arrow). There is no fold or bowel wall thickening. Results of wireless capsule endoscopy confirmed diffuse early Crohn disease. The patient responded to medical treatment.

View larger version (97K): [in a new window]   Figure 6a.  Giant Meckel diverticulum in a 21-year-old man who was referred for wireless capsule endoscopy because of chronic abdominal pain and anemia. Results of a small bowel follow-through study, radionuclide examination, and endoscopy of the upper and lower gastrointestinal tract were unremarkable. (a) Wireless capsule endoscopic image shows a shallow ulcer in one segment of the ileum (arrow). Other images showed ulcers in an adjacent segment and possibly in the colon. Double-contrast barium enteroclysis was requested to determine the extent of Crohn disease. (b) Double-contrast air-barium enteroclysis image shows a large saccular dilatation (arrowheads) in a pelvic segment of the ileum. Scattered ulcerations (arrow) are seen adjacent to the point of attachment of the dilatation to a normal-appearing loop of ileum. Results of surgery confirmed the presence of a giant Meckel diverticulum with ulcerations. There was no evidence of Crohn disease.

View larger version (142K): [in a new window]   Figure 6b.  Giant Meckel diverticulum in a 21-year-old man who was referred for wireless capsule endoscopy because of chronic abdominal pain and anemia. Results of a small bowel follow-through study, radionuclide examination, and endoscopy of the upper and lower gastrointestinal tract were unremarkable. (a) Wireless capsule endoscopic image shows a shallow ulcer in one segment of the ileum (arrow). Other images showed ulcers in an adjacent segment and possibly in the colon. Double-contrast barium enteroclysis was requested to determine the extent of Crohn disease. (b) Double-contrast air-barium enteroclysis image shows a large saccular dilatation (arrowheads) in a pelvic segment of the ileum. Scattered ulcerations (arrow) are seen adjacent to the point of attachment of the dilatation to a normal-appearing loop of ileum. Results of surgery confirmed the presence of a giant Meckel diverticulum with ulcerations. There was no evidence of Crohn disease.