Protocol Based On the Rapid RT Real Time Viewer to Prevent Incomplete Capsule Endoscopy Studies

Abstract

Introduction: Capsule endoscopy (CE) has demonstrated its utility to study the small bowel (SB). However, in up to 16% of the studies the cecum is not reached, leaving a variable non-visualized extension of intestine and thus potentially compromising the validity of the study. Around 3% of those cases are secondary to capsule retention from different recognizable causes. In the rest the cause unknown as the capsule is excreted later without problems. The role of delayed gastric emptying in those cases is controversial. The AGILE patency capsule (Given Imaging®) was designed to help prevent capsule retention and the Rapid RT (Given Imaging®) was designed to allow real time view of the capsule images but there are no strategies designed to ensure CE study completion. Aim: To evaluate the efficacy and outcomes of a protocol based on the use of the Rapid RT real time viewer to prevent incomplete CE studies of unknown cause. Material and Methods: Prospective study of PillCam SB2 (Given Imaging ®) CE studies performed at our institution between February and September 2008. Patients prepared with a minimal PEG solution (750cc). The Rapid RT was used to assess passage of the CE into the SB at 30 and 60 min. If still in the stomach at 60min, erythromycin 250mg i.v. was infused slowly over 30min. Another check was made 45 minutes later and if still in the stomach endoscopy was performed to advance the CE into the small bowel. The Rapid RT was also used to confirm arrival to the colon. A check was made at 6h and 30min, if the CE was still in the SB and no obvious cause of retention or symptoms were present, 250ml of PEG solution were administered. This strategy was repeated every 30min until the end of the battery life. Results: Thirty seven patients (12M: 25F;man age 47) were included. The capsule had passed into the SB at 60 min in 32patients. Five patients (13.5%) were infused erythromycin and of those one (2.7%) required upper endoscopy to advance the CE into the SB. The CE had reached the colon at 6h30min in 29 patients (78.3%) while in another 6 patients (16.2%) one dose of PEG solution was sufficient to achieve passage into the colon. Capsule retention occurred in two patients (5.4%) due to a duodenal stricture (1) and a tight ileostomy (1) that were visualized by the real time viewer. Both were solved by endoscopic means. No incomplete studies from unknown causes were registered. Conclusions: Our protocol based on the use of the Rapid RT real time viewer is effective to prevent incomplete CE studies due to delayed gastric emptying or unknown reasons. Studies comparing this approach with other strategies are warranted.