Capsule Endoscopy, Transit Times, and Whipple’s Disease

We read with interest the recent case report by Fritscher-Ravens et al. [1], in which they described a patient with refractory Whipple’s disease, explored by capsule endoscopy. The authors made two interesting observations: firstly, that the intestinal lesions of Whipple’s disease appear to involve the whole of the small intestine; and, secondly, that malabsorption could at least partly result from accelerated intestinal transit in patients with Whipple’s disease, as they measured a transit time of the capsule through the small bowel of 2 hours 43 minutes (163 minutes).

We recently had the opportunity to observe a similar case of Whipple’s disease in a 65-year-old man, investigated with capsule endoscopy before and 10 weeks after treatment commenced (sulfamethoxazole 400 mg and trimethoprim 80 mg, twice a day). The first capsule recording showed that the abnormal mucosa extended throughout both the jejunum and the ileum (Figure [1]). The mucosa appeared edematous, friable and hemorrhagic, with diffuse erosions and serpiginous ulcers. After 10 weeks of treatment, the patient had improved markedly from the clinical point of view. A second capsule endoscopy was performed then which showed an almost normal pattern of the jejunal and ileal mucosa with normal villi and some areas of lymphatic stasis (Figure [2]).

Figure 1 Capsule endoscopy image showing the typical mucosal pattern of the small intestine in untreated Whipple’s disease, with areas of edematous, friable, and hemorrhagic mucosa, diffuse erosions, and serpiginous ulcers.

Figure 2 Capsule image after 10 weeks of treatment with co-trimoxazole, showing recovery of an almost normal mucosal pattern. The only abnormality is lymphatic stasis with a whitish appearance of some villi.

We agree with Fritscher-Ravens et al. that capsule endoscopy may demonstrate a more extensive involvement of the small intestine in Whipple’s disease than has been described previously, as this technique allows endoscopic examination of the whole small bowel. We would like to point out that other intestinal diseases previously described as involving mainly the proximal part of the small bowel have similarly been shown to extend to the distal part, as we were able to demonstrate in one patient with abetalipoproteinemia [2].

On the other hand, we rather disagree with the conclusion drawn by Fritscher-Ravens et al. about the causal role of intestinal dysmotility in malabsorption in patients with Whipple’s disease. Capsule transit times must be interprated very cautiously as markers of intestinal motility. In the patient we studied, the intestinal transit time of the capsule was 425 minutes, calculated as the time between the first duodenal image and the first colonic image from the times indicated by the time counter of the software used during capsule procedures. At the second procedure, the transit time of the capsule through the small intestine was dramatically reduced at 274 minutes. In our experience, the Whipple’s disease delayed the intestinal transit time of the capsule. The pretreatment transit time measured in our patient was much longer than the average transit time we reported previously in bleeding patients (314 ± 96 minutes, range 101 - 381 minutes) [3]. On the other hand, intestinal transit times measured using various techniques based on the hydrogen breath test are in the range of 90 - 210 minutes [4], close to those measured in bleeding patients. We would therefore rather conclude that the transit time of 163 minutes reported by Fritscher-Ravens et al. has to be considered as normal and that Whipple’s disease might delay intestinal transit, rather than accelerate it. Furthermore, our observation suggests that motility disturbances may correlate with the severity of the mucosal lesions.

In conclusion, speculation about the role of motility disturbances in malabsorption in Whipple’s disease must be very cautious because transit times may vary dramatically, both between patients and within individual patients before and after treatment. However, capsule endoscopy allows a complete examination of the small bowel and may help to show that the extent of lesions might be larger than previously described in many conditions. Transit times of the endoscopic capsule need to be further assessed in patients with intestinal diseases and compared with investigations using other methods. In the near future, capsule endoscopy might help us to reassess the clinical description of several intestinal diseases.

References

• 1 Fritscher-Ravens A, Swain C P, von Herbay A. Refractory Whipple’s disease with anaemia: first lessons from capsule endoscopy.  Endoscopy. 2004;  36 659-662
• 2 Gay G, Fassler I, Florent C, Delvaux M. Malabsorption. In: Halpern M, Jacob H (eds). Atlas of Capsule Endoscopy.  Yoqneam; Given Imaging 2002: 83-101
• 3 Saurin J C, Delvaux M, Gaudin J L. et al . Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: comparative, blinded study with video push-enteroscopy.  Endoscopy. 2003;  35 576-584
• 4 Wutzke K D, Heine W E, Plath C. et al . Evaluation of oro-cecal transit time: a comparison of the lactose-[13C, 15N]ureide 13CO2- and the lactulose H2-breath test in humans.  Eur J Clin Nutr. 1997;  51 11-19