SMALL INTESTINE: Edited by Reena Sidhu
The small bowel edition delves from every day scenarios to demistfying difficult to treat entities. Sanders et al. (pp. 199–205) discuss the overlap between irritable bowel syndrome and noncoeliac gluten sensitivity (NCGS). There is inherent difficulty in making the diagnosis of NCGS with the absence of biomarkers. The several components of the wheat grain and associated impact on the gut are discussed within the paradigm of NCGS. Is it gluten or the Fermentable Oligosaccharides, disaccharides, monosaccharides and Polyols to blame? – The authors suggest using Salerno's expert criteria to help with the diagnosis .
There is several diagnosis to consider in the investigation of diarrhoea (pp. 206–212). There is increased interest with point of care testing for coeliac disease but this has yet to be incorporated into routine clinical care. The study by Sarna et al. is of interest demonstrating evidence that testing human leukocyte antigen: HLA-DQ-gluten tetramers by flow cytometry could identify treated coeliac disease as effectively as untreated.
Small bowel ulcers can pose a diagnostic dilemma to clinicians outside the territory of inflammatory bowel disease (IBD). Keuchel et al. (pp. 213–222) stress that the macroscopic appearance of small bowel ulcers on capsule endoscopy cannot provide a reliable differentiation and even histology can be nonspecific in some cases. A thorough clinical history, blood work up and drug history is essential including the surreptious use of NSAIDs. New evidence suggest that prostaglandin analogues; misoprostol may have a role in healing of ulcers secondary to aspirin damage . Could this be a new therapy for small bowel ulcers due to other causes? There is also evidence of Rifaximin use in healing ulcers secondary to diclofenac highlighting the role of bacteria in NSAID damage .
In the setting of IBD, the reliability of the diagnostic yield of small bowel ulcers on capsule endoscopy continue to be questioned (pp. 223–234). The literature suggests that the yield from histology using device assisted enteroscopy (DAE) is often low. There has been expansion of use of capsule endoscopy in post operative Crohn's disease and to look for evidence of proximal disease. Capsule endoscopy fares better than radiology in this setting (pp. 235–242).
However, we need more studies to show that it positively alters patient management. DAE and endoscopic dilatation offers a new modality of treating small bowel strictures while there is growing evidence of use of adalumimab in treating symptomatic small bowel strictures due to Crohn's disease .
The diagnosis of autoimmune enteropathy remains challenging. Elli et al. (pp. 243–249) highlight important medication including AT1 antagonists that may cause histological overlap. A multifaceted approach is required in making the diagnosis of autoimmune enteropathy, combining clinical history, serology (including tests directed to support diagnosis or to exclude other confounding diseases) and histology (including molecular analysis). Despite time moving on, there is paucity of literature on treatment regimens. Steroids remain the main modality of choice for autoimmune enteropathy.
Small bowel polyps are not uncommon findings with the increasing use of capsule endoscopy. Saurin et al. (pp. 250–256) discuss the different modalities of investigation and how to deal with polyps and recognition of benign disease such as lymphangiectasia and lipomas. Polyps corresponding to familial syndromes are detailed and they highlight newer endoscopic treatment for small bowel haemangiomas with the use of polidocanol injection .
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Catassi C, Elli L, Bonaz B, et al. Diagnosis of non-celiac gluten sensitivity (NCGS): the Salerno experts’ criteria. Nutrients 2015; 7:4966–4977.
2. Sarna VK, Lundin KEA, Mørkrid L, et al. HLA DQ gluten Tetramer Blood Test accurately identifies patients with and without celiac disease in absence of gluten consumption. Gastroenterology 2018; 154:886–896.
3. Kyaw MH, Otani K, Ching JYL, et al. Misoprostol heals small bowel ulcers in aspirin users with small bowel bleeding. Gastroenterology 2018; 155:1090–1097.e1.
4. Scarpignato C, Dolak W, Lanas A, et al. Rifaximin reduces the number and severity of intestinal lesions associated with use of nonsteroidal anti-inflammatory drugs in humans. Gastroenterology 2017; 152:980–982. e983.
5. Bouhnik Y, Mary JY. Adalimumab in Crohn's disease and symptomatic small bowel strictures. Gut 2018; 67:199.
6. Igawa A, Oka S, Tanaka S, et al. Polidocanol injection therapy for small-bowel hemangioma by using double-balloon endoscopy. Gastrointest Endosc 2016; 84:163–167.