small intestine biopsy
Small Intestine Biopsy
A biopsy is a diagnostic procedure in which tissue or cells are removed from a part of the body and specially prepared for examination under a microscope. When the tissue involved is part of the small intestine, the procedure is called a small-intestine (or small-bowel) biopsy.
The small-bowel biopsy is used to diagnose and confirm disease of the intestinal mucosa (the lining of the small intestine). The test is most commonly done to test for tumors of the small bowel or malabsorption syndromes.
Due to the slight risk of bleeding during or after this procedure, aspirin, aspirin-containing medications, nonsteroidal anti-inflammatory drugs, and anticoagulants and antiplatelet drugs should be withheld for at least five days before the test.
The small intestine is approximately 21 ft (6.4m). It has three sections: the duodenum (a short, curved segment fixed to the back wall of the abdomen), the jejunum, and the ileum (two larger, coiled, and mobile segments). Some digestion occurs in the stomach, but the small intestine is mainly responsible for digestion and absorption of foods.
Malabsorption syndromes occur when certain conditions result in impaired absorption of nutrients, vitamins, or minerals from the diet by the lining of the small intestine. For example, injury to the intestinal lining can interfere with absorption, as can infections, intestinal parasites, some drugs, blockage of the lymphatic vessels, poor blood supply to the intestine, or diseases like sprue.
Malabsorption is suspected when a patient not only loses weight, but has diarrhea and nutritional deficiencies despite eating well (weight loss alone can have other causes). Laboratory tests like fecal fat, a measurement of fat in stool samples collected over 72 hours, are the most reliable tests for diagnosing fat malabsorption, but abnormalities of the small intestine itself are diagnosed by small-intestine biopsy.
Several different methods are used to detect abnormalities of the small intestine. A tissue specimen can be obtained by using an endoscope (a flexible viewing tube), or by using a thin tube with a small cutting instrument at the end. This latter procedure is ordered when specimens larger than those provided by endoscopic biopsy are needed, because it allows removal of tissue from areas beyond the reach of an endoscope.
Several similar types of capsules are used for tissue collection. In each, a mercury-weighted bag is attached to one end of the capsule, while a thin polyethylene tube about 5 ft (1.5m) long is attached to the other end. Once the bag, capsule, and tube are in place in the small bowel, suction on the tube draws the tissue into the capsule and closes it, cutting off the piece of tissue within. This is an invasive procedure, but it causes little pain and complications are rare.
A newer method of obtaining diagnostic information about the small intestine was approved by the Food and Drug Administration (FDA) in 2001. Known as the M2A Imaging System, the device was developed by a company in Atlanta, Georgia. The M2A system consists of an imaging capsule, a portable belt-pack image receiver and recorder, and a specially modified computer. The patient swallows the capsule, which is the size of a large pill. A miniature lens in the capsule transmits images through an antenna/transmitter to the belt-pack receiver, which the patient wears under ordinary clothing as he or she goes about daily activities. The belt-pack recording device is returned after seven or eight hours to the doctor, who then examines the images recorded as a digital video. The capsule itself is simply allowed to pass through the digestive tract.
Preparation requires only fasting the night before the M2A examination and taking nothing but clear liquids for two hours after swallowing the capsule. After four hours the patient can eat food without interfering with the test. As of the early 2000s, the M2A system is used to evaluate gastrointestinal bleeding from unknown causes, inflammatory bowel disease, some malabsorption syndromes, and to monitor surgical patients following small-bowel transplantation. The system has shown good results in detecting Crohn's disease undiagnosed by conventional methods.
Small-intestine biopsy procedure
After application of a topical anesthetic to the back of the patient's throat, the capsule and the tube are introduced, and the patient is asked to swallow as the tube is advanced. The patient is then placed on the right side and the instrument tip is advanced another 20 in (51cm) or so. The tube's position is checked by fluoroscopy or by instilling air through the tube and listening with a stethoscope for air to enter the stomach.
The tube is advanced 2-4 in (5.1-10 cm)at a time to pass the capsule through the stomach outlet (pylorus). When fluoroscopy confirms that the capsule has passed the pylorus, small samples of small intestine tissue are obtained by the instrument's cutting edge, after which the instrument and tube are withdrawn. The entire procedure may be completed in minutes.
This procedure requires tissue specimens from the small intestine through means of a tube inserted into the stomach through the mouth. The patient is to withhold food and fluids for at least eight hours before the test.
The patient should not have anything to eat or drink until the topical anesthetic wears off (usually about one to two hours). If intravenous sedatives were administered during the procedure, the patient should not drive for the remainder of the day. Complications from this procedure are uncommon, but can occur. The patient is to note any abdominal pain or bleeding and report either immediately to the doctor.
Complications from this procedure are rare, but can include bleeding (hemorrhage), bacterial infection with fever and pain, and bowel puncture (perforation). The patient should immediately report any abdominal pain or bleeding to the physician in charge. Biopsy is contraindicated in uncooperative patients, those taking aspirin or anticoagulants, and in those with uncontrolled bleeding disorders.
Normal results are no abnormalities seen on gross examination of the specimen(s) or under the microscope after tissue preparation.
Small-intestine tissue exhibiting abnormalities may indicate Whipple's disease, a malabsorption disease; lymphoma, a group of cancers; and parasitic infections like giardiasis, strongyloidiasis, and coccidiosis. When biopsy indicates celiac sprue (a malabsorption disorder), infectious gastroenteritis (inflammation of the gastrointestinal tract), folate and B12 deficiency, or malnutrition, confirmation studies are needed for conclusive diagnosis.
Beers, Mark H., MD, and Robert Berkow, MD., editors. "Malabsorption Syndromes." Section 3, Chapter 30 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
Beers, Mark H., MD, and Robert Berkow, MD., editors. "Small-Bowel Tumors." Section 3, Chapter 34 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
Adler, Douglas J., MD, and Christopher J. Gostout, MD. "Wireless Capsule Endoscopy." Hospital Physician May 2003: 17-22.
Ge, Z. Z., Y. B. Hu, and S. D. Xiao. "Capsule Endoscopy in Diagnosis of Small Bowel Crohn's Disease." World Journal of Gastroenterology 10 (May 1, 2004): 1349-1352.
Thompson, B. F., L. C. Fry, C. D. Wells, et al. "The Spectrum of GI Strongyloidiasis: An Endoscopic-Pathologic Study." Gastrointestinal Endoscopy 59 (June 2004): 906-910.
Sprue — A disorder of impaired absorption of nutrients from the diet by the small intestine (malabsorption), resulting in malnutrition. Two forms of sprue exist: tropical sprue, which occurs mainly in tropical regions; and celiac sprue, which occurs more widely and is due to sensitivity to the wheat protein gluten.
Whipple's disease — A disorder of impaired absorption of nutrients by the small intestine. Symptoms include diarrhea, abdominal pain, progressive weight loss, joint pain, swollen lymph nodes, abnormal skin pigmentation, anemia, and fever. The precise cause is unknown, but it is probably due to an unidentified bacterial infection.
Wireless capsule endoscopy — A newer method of examining the small bowel by means of a capsule swallowed by the patient. The capsule contains a miniaturized lens and an antenna that transmits information to a belt-pack recorder worn by the patient during the day.