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Capsule endoscopy has been in clinical practice for approximately a decade. The original capsule was designed for the small bowel, followed by esophageal, patency and colonic capsules. The aim of the present guidelines are to update the readers with the mode and preparations for use of the various capsules, the indications, as well as absolute and relative contraindications for their use. This document was written by the advanced technology group within the Israel Gastroenterology Association and was edited by the members of the Israel Gastroenterology Association.

Background: The source of obscure bleeding is usually located in the small bowel. The use of capsule endoscopy (CE) has changed the management of these patients., Goals: To review our experience with the diagnosis of small bowel tumors by CE in patients with obscure overt gastrointestinal bleeding., Methods: Retrospective analysis of CE examinations performed consecutively in two university-affiliated hospitals., Results: Among 156 patients who underwent CE examination (including 58 patients with obscure overt bleeding), five patients, all of whom presented with melena, were diagnosed as having a small bowel tumor. Three tumors were found in one patient (two ileal carcinoids and one ileal benign stromal tumor). A jejunal benign stromal tumor was diagnosed in two other patients by push enteroscopy. One of these was missed by a subsequent capsule endoscopy examination, and in the other, only active bleeding was detected by prior capsule endoscopy. In two patients, three small tumors were detected, beyond the reach of push enteroscopy, but surgical confirmation was not available. No tumors were found among patients in whom the indication for CE examination was not obscure overt bleeding., Conclusions: The possibility of finding a small bowel tumor emphasizes the role of capsule endoscopy in patients with obscure overt gastrointestinal bleeding. Push enteroscopy should be performed when capsule endoscopy yields negative or only suspicious findings.

Background: Inflammatory bowel disease (IBD) is caused by a combination of genetic, immunological and environmental factors. Despite recent advances in the study of IBD pathogenesis, including the discovery of the NOD2/CARD15 mutation in 40% of Crohn's Disease (CD) patients, in most IBD patients no known mutations have yet been discovered. The interleukin (IL)-13 gene is located near the IBD5 locus on chromosome 5q31, known to be in linkage disequilibrium with CD. IL-13 has a role in the pathogenesis of several chronic inflammatory diseases including IBD. The +2044G/A mutation, which encodes an IL-13 protein with glutamine instead of arginine, has been associated with various inflammatory conditions. However, its role in IBD has not been defined., Aim: This is a study of the role of the IL-13 gene +2044G/A mutation in the susceptibility to and phenotype of IBD., Methods: Two hundred and eighty-five patients with CD and 111 cases of ulcerative colitis (UC) were enrolled in the study. Mutation frequency was determined using restriction fragment length polymorphism study in IBD patients and 178 healthy ethnically matched controls. The mutated allele frequency was determined in various clinical sub-groups of IBD patients. Statistical significance of the differences in allele frequency in CD and UC patients and healthy controls was determined., Results: The +2044G/A allele frequency was similar in CD, UC and healthy controls (23.3%, 19.4%, 19.6%, respectively, p = 0.294). There was no significant association of +2044G/A mutation carriage with specific phenotypes of CD and UC., Conclusion: The IL-13 gene +2044G/A mutation has no significant role in susceptibility to and phenotype of IBD.

Background: Phosphate is an obligatory component of cellular function. Serum, levels are maintained within narrow levels by regulatory mechanisms. The normal range of phosphate concentration is 2.5-4.5 mg/dL. In certain clinical situations these mechanisms are insufficient and hypophosphatemia ensues., Aim: This study aimed to compare hospitalization course and clinical outcome of patients with moderate hypophosphatemia (1.0-2.0 mg/dl) with patients with extreme hypophosphatemia (< 1.0 mg/dL)., Methods: Patients who had at least one measurement of serum phosphate level of 1.0 mg/dL or less comprised the extreme hypophosphatemic group. Patients with at least one serum, phosphate level of between 1.0 and 2.0 mg./dL, but never had a phosphate level of less than 1.0 mg/dL comprised the moderate hypophosphatemic group. Files of 50 consecutive patients who had extreme hypophosphatemia and 100 consecutive patients with moderate hypophosphatemia were retrieved and analyzed., Results: The two groups of patients were similar with reference to age, gender ratio, background disease and indication for hospitalization. There was a higher proportion of obese patients in the moderate hypophosphatemia group. There was a higher proportion of patients who consumed alcohol on a regular basis before hospitalization in the extreme hypophosphatemic group. Patients suffering from extreme hypophosphatemia were more likely to be hospitalized in the intensive care unit and ventilated on hospitalization. Length of hospitalization was longer for the extreme hypophosphatemia group than for the moderate hypophosphatemia group. When comparing the group outcomes it was found that more patients with severe hypophosphatemia died., Conclusion: Severe hypophosphatemia is a severe metabolic derangement. It appears in critically sick patients, who should be followed closely and treated properly. The clinical relevance of moderate hypophosphatemia was not checked in this study.

Background: The continuing development in computer-based medical simulators provides an ideal platform for simulator-assisted training programs for medical trainees. Computer-based endoscopic simulators provide a virtual reality environment for training endoscopic procedures. This study illustrates the use of a comprehensive training model combining the use of endoscopic simulators with simulated (actor) patients (SP)., Aim: To evaluate the effectiveness of a comprehensive simulation workshop from the trainee perspective., Methods: Four case studies were developed with emphasis on communication skills. Three workshops with 10 fellows in each were conducted. During each workshop the trainees spent half of the time in SP case studies and the remaining half working with computerized endoscopic simulators with continuous guidance by an expert endoscopist. Questionnaires were completed by the fellows at the end of the workshop., Results: Seventy percent of the fellows felt that the endoscopic simulator was close or very close to reality for gastroscopy and 63% for colonoscopy. Eighty eight percent thought the close guidance was important for the learning process with the simulator. Eighty percent felt that the case studies were an important learning experience for risk management., Conclusion: Further evaluation of multi-modality simulation workshops in gastroenterologist training is needed to identify how best to incorporate this form of instruction into training for gastroenterologists.

Background: Colon cancer is the main cause of mortality among the gastrointestinal cancers in Israel. Early detection of the average risk population is recommended from the age of 50 to 75 years. Private departments of radiology aggressively advertise virtual colonoscopy for the early detection of colon cancer, although it is not recognised as such in any country., Methods: We collected all cases in which virtual colonoscopy was followed by endoscopic colonoscopy in the same patient from four medical centers in Israel., Results: Total discrepancy between the results of the two examinations was found in 2/3 of the patients. In some cases colon cancer was missed., Conclusions: The results presented herein, raise many questions and "red lights" as to the use of virtual colonoscopy in its present form for screening purposes in Israel unless it is in the setting of clinical research.

Background: Celiac disease may be present in many patterns other than the classical manifestations of diarrhea and malabsorption. The prevalence of celiac disease is greater than usually reported as mild cases are often undiagnosed. Diagnosing celiac disease may have major health significance., Aims: The aim of our study was to determine the prevalence of celiac disease in adults appearing for endoscopy with abdominal pain, in an open access setting., Methods: Two hundred and seventy consecutive, non-selected adult patients undergoing upper endoscopy for abdominal pain were included in the study. Three biopsies were routinely taken from the second part of the duodenum. In those cases with flattened villi on histology, antiendomysial antibody (AEA) was tested., Results: The prevalence of celiac disease among Israeli patients undergoing endoscopy for abdominal pain was high (1:23), greater than its highest reported prevalence in general populations (1:200-300)., Conclusions: Routine small bowel biopsies should be considered in patients undergoing upper endoscopy for otherwise unexplained pain.

Treatment is advocated for patients manifesting upper gastrointestinal bleeding. The medical arsenal consists of H2-receptor blockers and proton pump inhibitors. Studies which were performed to test the efficacy of H2-blockers for bleeding did not present consistent conclusions. In vitro studies proved that H2-blockers given parenterally lose their efficacy after 24 hours, and the pH-drops back to near pretreatment level (pH 2.7). Omeprazole, the oldest pump inhibitor on the market, when given parenterally affects pH-within 30 minutes and does not lose its efficacy in the forthcoming days. In a few studies, when given enterally/parenterally Omeprazole lowered rates of recurrent bleeding, surgery and the number and rate of blood units transfused. On the whole it seems that H2-blockers have little or no role in the treatment of patients with upper gastrointestinal bleeding, while a proton pump inhibitor is of probable therapeutic value. There is no definite answer as to whether the drug should be given enterally or parenterally. It seems logical to start treatment of high-risk patients parenterally and the rest of the patients enterally (orally or via a nasogastric tube).

In recent years there have been numerous reports of successful treatment of resistant ulcerative colitis with cyclosporin. A series of 9 patients with moderate to severe active ulcerative colitis was treated with cyclosporin between September 1993 and October 1994. All 9 had failed to respond to conventional therapy, including salazopyrine and intravenous corticosteroids. They underwent colonoscopy and after contraindications to therapy were ruled out, received intravenous cyclosporin, 4 mg/kg/day for 7-10 days. They were discharged on oral cyclosporin with average serum levels maintained at 200 ng/ml. Response was assessed using the clinical score system of Schroeder et al. 2 out of 9 patients (22%) responded with full clinical remissions lasting more than 6 months. 6 patients had partial responses to the intravenous therapy, but symptoms resumed shortly after its cessation. Factors predicting favorable response to cyclosporin therapy were a shorter duration of disease with a fulminant clinical course. The success rate was less than that reported in the literature, possibly because of comparatively low serum cyclosporin levels. Potential complications of therapy and high cost preclude the routine use of cyclosporin in ulcerative colitis. Larger controlled studies are required to assess its efficacy and safety. Until such studies are available, cyclosporin may be tried in poor surgical risks or those not yet ready psychologically for total colectomy.