Capsule Passage Research Articles

Novel upper gastrointestinal bleeding sensor capsule: a first human feasibility and safety trial.

Upper gastrointestinal bleeding (UGIB) is the most common GI condition requiring hospitalization, and can be diagnosed by direct visualization. The present study aimed to evaluate the safety and feasibility of using the PillSense system (EnteraSense Ltd.), a novel diagnostic tool designed for the rapid in vivo detection of UGIB, in human volunteers. In the present study, 10 volunteers swallowed a PillSense capsule, followed by 2 servings of an autologous blood preparation. Participants were monitored for capsule passage, overall tolerability of the procedure, and adverse events. The procedure was completed per the protocol established in the present study in 9/10 cases. In 9 of the subjects, after capsule ingestion, the device indicated the absence of blood with sensor output values of 1. After the ingestion of the first blood mixture, the sensor outputs of all devices increased from 2.8 to 4, indicating that each camera detected blood. The sensor output remained within that range after the ingestion of the second mixture; however, in one case, the baseline capsule signal was positive, because of a preexisting condition. The passage of the capsule was verified in all patients, and no adverse events were reported. The first trial of the PillSense system in human subjects demonstrated the feasibility, safety, and tolerability of utilizing this product as a novel, noninvasive, and easy-to-use triage tool for the diagnosis of patients suspected of having UGIB.

A novel blood-sensing capsule for rapid detection of upper GI bleeding: a prospective clinical trial

Background & AimsUpper gastrointestinal bleeding (UGIB) is a common medical emergency associated with high resource utilization, morbidity, and mortality. Timely esophagogastroduodenoscopy (EGD) can be challenging from personnel, resource, and access perspectives. PillSense (EnteraSense Ltd, Galway) is a novel swallowed bleeding sensor for detection of UGIB, anticipated to aid in patient triage and guide clinical decision-making for individuals with suspected UGIB. MethodsThis is a prospective open-label, single-arm comparative clinical trial of a novel bleeding sensor for patients with suspected UGIB performed at a tertiary care center. The PillSense System consists of an optical sensor and an external receiver that processes and displays data from the capsule as "Blood Detected" or "No Blood Detected". Patients underwent EGD within 4 hours of capsule administration; participants were followed up to 21 days to confirm capsule passage. Results126 patients were accrued to the study (59.5% males, mean age 62.4 ± 14.3 years). Sensitivity and specificity for detecting the presence of blood were 92.9% (p = 0.02) and 90.6% (p < 0.001), respectively. The capsule's positive and negative predictive values were 74.3% and 97.8%., respectively, and positive and negative likelihood ratios were 9.9 and 0.08, respectively. No adverse events or deaths occurred related to the PillSense System, and all capsules were excreted from patients on follow-up. ConclusionsThe PillSense System is safe and effective for detecting the presence of blood in patients evaluated for UGIB prior to upper GI endoscopy. It is a rapidly deployed tool, with easy-to-interpret results that will impact the diagnosis and triage of patients with suspected UGIB. (ClinicalTrials.gov, NCT05385224).

Regional Gastrointestinal Motility in Healthy Children.

The aim of the study was to evaluate the safety and use of the 3D-Transit system (Motilis SA, Lausanne, Switzerland) and to describe regional gastrointestinal transit times, segmental colonic transit times, and colonic movement patterns in healthy children. Twenty-one healthy children (11 girls, median age 10.5 years, range 7-15 years) were included. For evaluation of gastrointestinal transit times and colonic movement patterns, we used the minimally invasive electromagnetic 3D-Transit system. A small electromagnetic capsule (21.5 mm × 8.3 mm) was ingested and tracked through the gastrointestinal tract by a body-worn detector. Regional gastrointestinal transit times were assessed as time between capsule passage of anatomical landmarks. Colonic movement patterns were described and classified based on capsule movement velocity, direction, and distance. One child could not swallow the capsule and 20 children completed the study without any discomfort or side-effects. Median whole gut transit time was 33.6 (range 10.7-80.5) hours, median gastric emptying time was 1.9 (range 0.1-22.1) hours, median small intestinal transit time was 4.9 (range 1.1-15.1) hours, and median colonic transit time was 26.4 (range 6.8-74.5) hours. Median ascending colon/cecum transit time was 9.7 (range 0.3-48.1) hours, median transverse colon transit time was 5.6 (range 0.0-11.6) hours, median descending colon transit time was 2.6 (range 0.01-22.3) hours, and median sigmoid colon/rectum transit time was 7.5 (range 0.1-31.6) hours. Colonic movement patterns among children corresponded to those previously described in healthy adults. The 3D-Transit system is a well-tolerated and minimally invasive method for assessment of gastrointestinal motility in children.

2537 Case of an Incidental Small Bowel Adenocarcinoma Upon Surgical Evacuation of a Retained Video Capsule Endoscopy in a Patient With Crohn's Disease

INTRODUCTION: Here we report the case of a patient with Crohn's disease in whom a video capsule got lodged in a small bowel stricture and upon surgical evacuation of the capsule small bowel adenocarcinoma was incidentally found. This case emphasizes that it is important to consider small bowel adenocarcinoma in Crohn's disease patients with obstructive signs. This case also demonstrates the management of a retained capsule in Crohn's patients. CASE DESCRIPTION/METHODS: A 28 year old male with history of Crohn's disease presented for an evaluation of bright red blood per rectum and severe anemia. Initial evaluation with a colonoscopy and EGD revealed no source of bleeding and thus a video capsule was placed. Two days after placement of the capsule the patient began having severe abdominal pain. A KUB revealed that the capsule was still at the ileocecal valve, indicating that it was possibly stuck in a stricture. The patient was started on IV methylprednisolone in order to reduce inflammation to allow for passage of the capsule. Upon further evaluation, surgical intervention was necessary to remove the capsule. In the operating room the surgeons visualized a tumor in the jejunum arising from a Crohn's stricture. Despite multiple inspections of the resected small bowel the capsule could not be located. An intraoperative x-ray revealed the capsule to be in the splenic flexure of the colon indicating that the capsule passed through the stricture prior to resection. The final pathology revealed metastatic poorly differentiated adenocarcinoma. DISCUSSION: Small bowel adenocarcinoma is a recognized however overlooked complication of Crohn's disease. In patients with non-concerning colonoscopies with signs of obstruction (such as a retained capsule) and severe anemia, small bowel adenocarcinoma should be strongly considered. Capsule retention is often diagnosed via abdominal x-ray such as in our case. A retained capsule often remains asymptomatic however carries the risk of perforation, secondary obstruction, or ulceration. Double-balloon enteroscopy is considered the primary method for capsule retrieval however surgical exploration is often done. The concern for the capsule being lodged in a stricture in our patient made surgery the best option. We did first attempt IV methylprednisolone and within the five day interval prior to surgery the capsule had passed into the colon. In Crohn's disease patients, immunosuppressive medications such as steroids and infliximab have been shown to facilitate capsule passage.

Patient-oriented education and visual-aid intervention are inadequate to identify patients with potential capsule retention: a prospective randomized study

Background/aims: The key procedure-related risk with video capsule endoscopy (VCE) is capsule retention, which should be suspected in patients who have not reported capsule passage. The study aims were to determine the frequency of capsule passage visualization and the difference in self-reporting of capsule passage between patients who receive patient-oriented education (POE) and patients who receive POE and a visual aid intervention in the form of a wrist band (WB).Methods: This was a prospective randomized study that enrolled patients undergoing VCE. Patients were randomly assigned to a POE group versus a POE and WB group. POE consisted of verbal education and an information booklet. Both groups received instructions to notify the study team regarding capsule passage.Results: Sixty patients (mean age 57 ± 18 years; 61% female) were included. A total of 57 patients were included in the analysis (3 lost to follow-up; 28 in POE group; 29 in WB group). Capsule passage status was reported by 68% without significant difference between POE and WB groups (72% vs. 64%; p = .51). Capsule passage status was obtained from all 57 patients with the addition of a proactive follow-up. Only 56% (n = 32) reported visualizing capsule passage. Of the remaining patients who did not visualize capsule passage, 60% (n = 15) reported on this without significant difference between the POE and WB groups (p = .23).Conclusions: Lack of visualization of capsule passage is a poor indicator of retention. Self-reporting of VCE passage status is suboptimal and the addition of a visual aid did not improve this parameter.

The effect of macrogol administration on the quality of macroscopic images and transit time in canine capsule endoscopy.

The present experiment evaluated the quality of macroscopic images and the mean time of capsule passage through different sections of the gastrointestinal tract in dogs subjected to different preparation protocols before capsule endoscopy. In the first examination, the colonoscopy prepara- tion protocol was applied, and in the second examination, the animals were administered macrogol. The study revealed that macrogol administration before capsule endoscopy significantly improved the quality of macroscopic images. The colonoscopy preparation protocol may not support accurate visualization of the large bowel mucosa and, in selected patients, also the small bowel mucosa. Macrogol administration had no effect on capsule transit time through the alimentary canal. Capsules used in endoscopic evaluations of the small bowel in humans may have limited applications in macro- scopic examinations of large bowel mucosa in dogs.

Sensitivity of the suspected blood indicator: An experimental study

To investigate whether suspected blood indicator (SBI) in capsule endoscopy (CE) is affected by background color and capsule passage velocity. Experimental models of the small intestine constructed from paper in a variety of colors were used to simulate the background colors observed in CE images. The background colors studied included very pale yellow, yellow, very pale magenta, light grayish pink, burnt sienna, and deep and dark brown, and red spots were attached inside them. An endoscopic capsule was manually passed through the models. The rate of detection of the red spots by the SBI was evaluated based on the colors of the models and the capsule passage velocities (0.5 cm/s, 1 cm/s, and 2 cm/s). The rate of detection of the red spots by the SBI differed significantly according to the background color of the model (P < 0.001). Detection rates were highest for backgrounds of very pale magenta, burnt sienna, and yellow, in that order. They were lowest for backgrounds of dark brown and very pale yellow. The rate of detection of red spots by the SBI tended to decrease at rapid capsule passage velocities (1-2 cm/s) compared to slow velocities (0.5 cm/s) for backgrounds of very pale yellow (P = 0.042), yellow (P = 0.001), very pale magenta (P = 0.002), and burnt sienna (P = 0.001). No significant differences in the rate of detection were observed according to velocity for light grayish pink (P = 0.643) or dark brown (P = 0.396). SBI sensitivity was affected by background color and capsule passage velocity in the models. These findings may facilitate the rapid detection of bleeding lesions by CE.

Distribution of bleeding gastrointestinal angioectasias in a Western population

To define which segments of the gastrointestinal tract are most likely to yield angioectasias for ablative therapy. A retrospective chart review was performed for patients treated in the Louisiana State University Health Sciences Center Gastroenterology clinics between the dates of July 1, 2007 and October 1, 2010. The selection of cases for review was initiated by use of our electronic medical record to identify all patients with a diagnosis of angioectasia, angiodysplasia, or arteriovenous malformation. Of these cases, chart reviews identified patients who had a complete evaluation of their gastrointestinal tract as defined by at least one upper endoscopy, colonoscopy and small bowel capsule endoscopy within the past three years. Patients without evidence of overt gastrointestinal bleeding or iron deficiency anemia associated with intestinal angioectasias were classified as asymptomatic and excluded from this analysis. Thirty-five patients with confirmed, bleeding intestinal angioectasias who had undergone complete endoscopic evaluation of the gastrointestinal tract were included in the final analysis. A total of 127 cases were reviewed. Sixty-six were excluded during subsequent screening due to lack of complete small bowel evaluation and/or lack of documentation of overt bleeding or iron deficiency anemia. The 61 remaining cases were carefully examined with independent review of endoscopic images as well as complete capsule endoscopy videos. This analysis excluded 26 additional cases due to insufficient records/images for review, incomplete capsule examination, poor capsule visualization or lack of confirmation of typical angioectasias by the principal investigator on independent review. Thirty-five cases met criteria for final analysis. All study patients were age 50 years or older and 13 patients (37.1%) had chronic kidney disease stage 3 or higher. Twenty of 35 patients were taking aspirin (81 mg or 325 mg), clopidogrel, and/or warfarin, with 8/20 on combination therapy. The number and location of angioectasis was documented for each case. Lesions were then classified into the following segments of the gastrointestinal tract: esophagus, stomach, duodenum, jejunum, ileum, right colon and left colon. The location of lesions within the small bowel observed by capsule endoscopy was generally defined by percentage of total small bowel transit time with times of 0%-9%, 10%-39%, and 40%-100% corresponding to the duodenum, jejunum and ileum, respectively. Independent review of complete capsule studies allowed for deviation from this guideline if capsule passage was delayed in one or more segments. In addition, the location and number of angioectasias observed in the small bowel was further modified or confirmed by subsequent device-assisted enteroscopy (DAE) performed in the 83% of cases. In our study population, angioectasias were most commonly found in the jejunum (80%) followed by the duodenum (51%), stomach (22.8%), and right colon (11.4%). Only two patients were found to have angioectasias in the ileum (5.7%). Twenty-one patients (60%) had angioectasias in more than one location. Patients being considered for endoscopic ablation of symptomatic angioectasias should undergo push enteroscopy or anterograde DAE and re-inspection of the right colon.

Inpatient capsule endoscopy leads to frequent incomplete small bowel examinations

To examine the predictive factors of capsule endoscopy (CE) completion rate (CECR) including the effect of inpatient and outpatient status. We identified 355 consecutive patients who completed CE at Rush University Medical Center between March 2003 and October 2005. Subjects for CE had either nothing by mouth or clear liquids for the afternoon and evening of the day before the procedure. CE exams were reviewed by two physicians who were unaware of the study hypotheses. After retrospective analysis, 21 cases were excluded due to capsule malfunction, prior gastric surgery, endoscopic capsule placement or insufficient data. Of the remaining 334 exams [264 out-patient (OP), 70 in-patient (IP)], CE indications, findings, location of the patients [IP vs OP and intensive care unit (ICU) vs general medical floor (GMF)] and gastrointestinal transit times were analyzed. Statistical analysis was completed using SPSS version 17 (Chicago, IL). Chi-square, t test or fisher exact-tests were used as appropriate. Multivariate logistic regression analysis was used to identify variables associated with incomplete CE exams. The mean age for the entire study population was 54.7 years. Sixty-one percent of the study population was female, and gender was not different between IPs vs OPs (P = 0.07). The overall incomplete CECR was 14% in our study. Overt obscure gastrointestinal bleeding (OGB) was significantly more common for the IP CE (P = 0.0001), while abdominal pain and assessment of IBD were more frequent indications for the OP CE exams (P = 0.002 and P = 0.01, respectively). Occult OGB was the most common indication and arteriovenous malformations were the most common finding both in the IPs and OPs. The capsule did not enter the small bowel (SB) in 6/70 IPs and 8/264 OPs (P = 0.04). The capsule never reached the cecum in 31.4% (22/70) of IP vs 9.5% (25/ 264) of OP examinations (P < 0.001). The mean gastric transit time (GTT) was delayed in IPs compared to OPs, 98.5 ± 139.5 min vs 60.4 ± 92.6 min (P = 0.008). Minimal SB transit time was significantly prolonged in the IP compared to the OP setting [IP = 275.1 ± 111.6 min vs OP = 244.0 ± 104.3 min (P = 0.037)]. CECR was also significantly higher in the subgroup of patients with OGB who had OP vs IP exams (95% vs 80% respectively, P = 0.001). The proportion of patients with incomplete exams was higher in the ICU (n = 7/13, 54%) as compared to the GMF (n = 15/57, 26%) (P = 0.05). There was only a single permanent SB retention case which was secondary to a previously unknown SB stricture, and the remaining incomplete SB exams were due to slow transit. Medications which affect gastrointestinal system motility were tested both individually and also in aggregate in univariate analysis in hospitalized patients (ICU and GMF) and were not predictive of incomplete capsule passage (P > 0.05). Patient location (IP vs OP) and GTT were independent predictors of incomplete CE exams (P < 0.001 and P = 0.008, respectively). Incomplete CE is a multifactorial problem. Patient location and related factors such as severity of illness and sedentary status may contribute to incomplete exams.

Lessons from Korean Capsule Endoscopy Multicenter Studies

Since its development, video capsule endoscopy (VCE) introduced a new area in the study of small bowel disease. We reviewed and discussed current issues from Korean capsule endoscopy multicenter studies. Main results are as follows: First, there was no significant difference in diagnostic yield according to the method of bowel preparation. Second, VCE represents a reliable and influential screening measure in patients with chronic unexplained abdominal pain and this technique could successfully alter the clinical course especially for patients with small bowel tumor. Third, the inter-observer variation in the expert group was lower than that in trainee group. Fourth, studies about the spontaneous capsule passage after retention showed 2.5% of retention rate and the size of lumen was an important factor of spontaneous passage. We need larger scale studies on the effect of bowel preparation methods on the diagnostic yield and further studies about the learning curve or unique capsule endoscopic findings for small intestinal diseases in Korean patients.

Accuracy of the Patency Capsule to Exclude Small Bowel Strictures in Crohnʼs Disease: Is it Better to be Safe or Sorry?

Purpose: Capsule endoscopy (CE) is now a well established investigation for suspected Crohn's disease (CD). Its use in established CD has been limited, due in part to the relatively high risk (˜5%) of capsule retention. Barium radiography (SBFT) has not been found to be reliable to assure small bowel patency prior to CE in CD. The use of a patency capsule has thus been proposed as an alternate screening test for this purpose. Evacuation of the dummy capsule from the small bowel within a 30 h window indicates small bowel patency, whereas its retention beyond this time has been taken to imply a potential luminal stricture, contraindicating CE. The purpose of this study was to evaluate the clinical utility and safety of the patency capsule in established CD. Methods: Outcomes of consecutive CD cases referred for CE were reviewed before and after the systematic use of a patency capsule to screen for small bowel patency. Plain abdominal radiology (AxR) was used to localize the patency capsule 30 +/− 2 hr after ingestion. Results: Before the FDA approved introduction of the Agile patency capsule in 2006, we carried out small bowel CE in 31 CD patients without obstructive symptoms or any strictures seen on SBFT. Capsule retention occurred in 2 (6.7%) of these cases. Subsequently, 37 consecutive CD patients first underwent the patency capsule exam. Among these, 5 were denied CE because the patency capsule was localized to the small bowel radiologically 30 h after ingestion. Among the 32 others who underwent the CE exam, capsule retention occurred in 1 (3.2%) case. For the most recent 4 CD patients in whom the patency capsule position was deemed to be in the small bowel or its location was doubtful at 30 h, a second AxR was carried out at 48-60 h. In 3 of the latter, the repeat imaging showed that the patency capsule was eliminated intact from the small bowel. All 3 subsequently underwent a successful CE exam. CE was denied in the 1 remaining case with prolonged small bowel retention of the patency capsule. Conclusion: Subclinical intestinal stenoses are frequent in CD and conventional radiologic investigations have a low sensitivity for their detection. Use of a patency capsule use appears to reduce, but not completely eliminate the risk of capsule retention. However, the “safe” reliance on a 30 hour cut-off for patency capsule elimination from the small bowel may preclude a clinically worthwhile CE study. Further trials are required to validate the safety and clinical value of a delayed cut-off (˜48 hr) for intact patency capsule passage. Disclosure: Dr Ernest G Seidman- Consultant, member of Speaker's Bureau, and recipeint of research support from Given Imaging Inc. Given Imaging Inc. supplied a small number of patency capsules free of charge.

A Wireless Insufflation System for Capsular Endoscopes

Swallowable capsule-based cameras (e.g., the Given Imaging PillCam and competitors) are rapidly becoming the gold standard for diagnosis in the gastrointestinal (GI) tract. However, definitive diagnosis is still often precluded by the inability to control capsule position and orientation. This has inspired a number of active positioning strategies including augmenting the capsule with legs or other appendages, or incorporating magnets which can apply forces and torques in response to an external magnetic field. Furthermore, the loose, mucous coated, elastic intestine is generally deflated during capsule passage, making it challenging to view the entire internal surface adequately without the insufflation that is relied upon in traditional endoscopy. To address these challenges, we propose a new fluid-powered system that permits insufflation from a wireless capsule platform. This is accomplished by carrying a small reservoir of biocompatible liquid onboard the capsule which vaporizes and expands when released through a small onboard solenoid valve. The internal components of the capsule consist of two 3V Lithium coin cell batteries (VL621, Panasonic, Inc.) which charge 3 Tantalum capacitors (TAJB157M006R, AVX Corporation, Inc.) that fire the solenoid valve (S120, Lee Company, Inc.). In our initial proof-of-concept study, we have packaged all components in a 26 mm long by 11 mm diameter capsule. The fluid used in initial experiments is biocompatible Perfluoropentane, although any of a variety of biocompatible fluids that can be liquefied with light pressurization may be used. Perfluoropentane, developed for lung lavage, is a liquid at room temperature and becomes gaseous at body temperature. We note that pneumatic pressure produced in this way may be used for a variety of objectives, including powering biopsy collection devices or other mechanisms within the capsule, or being vented to inflate the intestine. In initial experiments, we have harnessed the pressure to inflate a balloon at the front of the capsule which can distend tissue and thereby improve image quality. In experimental tests, only 0.2 ml of fluid was consumed in inflating the balloon to sufficient pressure to distend porcine intestine (see http://research.vuse.vanderbilt.edu/MEDLab for images of these experiments). Optimization of the capsule body and electrical components is currently underway. Including a wireless camera, all components are expected to fit within the dimensions of a commercial PillCam.

Capsule Endoscopy Interpretation by an Endoscopy Nurse – a Comparative Trial

Capsule endoscopy is a common, pain-free diagnostic procedure for the small bowel. However, interpretation of the whole video recording is a time-consuming and costly procedure that can take up to 2 hours. The aim of the present study is two-fold: first to study the accuracy of capsule endoscopy analysis between a trained endoscopy nurse and a physician and secondly to determine if pre-evaluation by nursing staff might be time-effective for capsule reading. This study is especially important given the increasing financial pressure on current health-care systems. A long-standing experienced endoscopy nurse, who was trained to read capsule endoscopy, and a physician, both blinded to the patient diagnosis and the other clinical findings reviewed 48 consecutive capsule endoscopy videos. The analyses of both the nurse and the physician were re-evaluated by an independent doctor regarding the agreement of the marked findings. Total time to read capsule endoscopy was significantly longer for the nurse's interpretation (63 +/- 26 min) as compared to the physician's interpretation (54 +/- 18 min, p < 0.01). The endoscopy nurse marked 236 thumbnails, whereas the doctor only marked 132 thumbnails. The nurse overlooked 4 of 64 relevant lesions (6 %), which had been detected by the physician. These overlooked lesions were not single important lesions, they were overlooked only in patients with multiple angiectasias of the small intestine, and thus the misdiagnosis was without clinical relevance. The physician overlooked 6 of 68 lesions detected by the nurse (9 %), also in patients with multiple angiodysplastic lesions and therefore without clinical relevance. On post-hoc analysis of the capsule video recordings the time needed by the physician to interpret the thumbnails marked by the nurse was 10 +/- 12 min. While there was no difference with respect to the estimated gastric emptying time (nurse 27 +/- 13 min vs. physician 28 +/- 14 min, n. s.), the estimated time of capsule passage through the ileocaecal valve was longer when interpreted by the endoscopy nurse (nurse 347 +/- 89 min vs. physician 326 +/- 74 min, n. s.). Nevertheless, the total cost for capsule pre-evaluation by the nurse was lower (13.23 euro vs. physician 17.82 euro). The endoscopy nurse detected 94 % of the significant lesions seen by the physician and no clinically relevant findings were overlooked. A pre-evaluation of the capsule video by trained staff is an accurate method and might be time effective.

Can we predict spontaneous capsule passage after retention? A nationwide study to evaluate the incidence and clinical outcomes of capsule retention

Although capsule endoscopy has become a central diagnostic tool for small-bowel evaluation, retention of a capsule remains a major concern. This study attempted to investigate the incidence and clinical outcomes of capsule retention, and to determine the factors predictive of spontaneous capsule passage after retention. Through a nationwide multicenter survey, we retrospectively reviewed the records of 1291 patients who had a capsule endoscopy between February 2002 and July 2006 in Korea. Clinical and procedural characteristics and postprocedural outcomes were analyzed for the cases with capsule retention. Capsule retention occurred in 2.5 % of total cases (32/1291). The major diseases accompanying capsule retention were Crohn's disease, malignant tumors, and tuberculous enterocolitis, in decreasing order. In 11 of the 32 patients (34.4 %), early surgical or endoscopic interventions were instituted for diagnosis or treatment of diseases before retention symptoms developed. The remaining 21 (65.6 %) patients initially received medical treatments. Of these, 10 (31.3 %) ultimately underwent surgical intervention due to the development of symptoms of intestinal obstruction or medical treatment failure. The other 11 (34.4 %) eventually passed the capsule. The presence of a larger lumen diameter (greater than two-thirds of the capsule diameter) at the stricture site was associated with spontaneous passage. Our large-scale study suggests that retention occurs infrequently during capsule endoscopy. Moreover, a retained capsule might indicate the best intervention for the offending pathology, or it may spontaneously pass in the long run, particularly in patients with less small bowel stricture.

Commentaire de travail de J. H. Cheon et al., pp. 1046

See also: Can we predict spontaneous capsule passage after retention? A nationwide study to evaluate the incidence and clinical outcomes of capsule retentionEndoscopy 2007; 39(12): 1046-1052DOI: 10.1055/s-2007-966978

Wireless Capsule Endoscopy (WCE) Is an Important Diagnostic and Management Tool of Gastrointestinal (GI) Acute and Chronic Graft Versus Host Disease (GVHD) after Allogeneic Hematopoietic Stem Cell Transplantation (AlloHSCT) and Identifies Gastroparesis as a Prominent Complication of GI GVHD.

Acute and Chronic GVHD are major complications of alloHSCT. GI GVHD can be difficult to diagnose especially early in its course or if involving the small intestine (SI). WCE is a new, noninvasive technology that allows for complete SI evaluation. The capsule transit can be measured and location tracked to determine GI hyper- or hypomotility states. We describe WCE in the diagnosis and management of GI disorders following alloHSCT. From 8/06 to 07/07, 11 alloHSCT pts with GI symptoms underwent WCE to assist in diagnosis, assess therapy response or to evaluate other GI pathology in pts with established GI acute or chronic GVHD. Pt symptoms included nausea, abdominal pain, diarrhea, vomiting and hematochezia. Concomitant studies included stool bacterial, fungal and viral cultures and C. difficile toxin assay, as well as EBV and CMV testing. Upper GI (esophagus, stomach and duodenum) and Lower GI (colon and terminal ileum) endoscopy (UGE, LGE) were performed and biopsies taken when clinically indicated. Each capsule records for 8 hours. Visual grading of the GI track was determined on a 5 point scale and labeled as Endoscopic GI Grading (EGG) (Neumann et al GI Endoscopy 2007): Grade 0, normal; Grade 1, loss of vascular marking and/or mild focal erythema; Grade 2, moderate edema and/or erythema; Grade 3, edema, erythema, erosions and/or bleeding; Grade 4, ulceration, exudates and bleeding. Pts underwent WCE at a median day 77 post HSCT (range 18–593) (See Table 1). Five pts had significant gastroparesis (gastric capsule passage ≥ 2 hours), 2 of whom (pts 1, 6) had capsule stomach retention for > 8 hours. The capsule was placed in the duodenum by EGD in pt 1 with capsule passage. The cecum was not visualized in 3 pts (pts 4, 10, 11) due to delayed SI transit. WCE findings usually correlated with UGE/LGE findings but SI lesions visualized by WCE were more severe than those seen on UGE/LGE (pts 1, 5, 8, 9, 11). Repeat WCE in pt 11 demonstrated resolving lesions confirming therapy efficacy. No pt had side effects attributable to WCE and the capsule was recovered in all pts. WCE is a useful tool to diagnose and assess GI acute and chronic GVHD especially involving the SI. It is well tolerated and less invasive than UGE/LGE, making serial examinations feasible. The demonstration of delayed gastric emptying led to the use of upper GI motility agents (metoclopramide) for therapy. GI GVHD has been considered a hypermotility disorder. This study demonstrates that colonic hypermotility can occur with gastric hypomotility and that symptomatic therapy must be specific for upper and lower GI tract pathology.Patient #UGE or LGEUGE/LGE Day post HSCTUGE/LGE EGG GradeTissue Biopsy consistent with GVHDWCE Day post HSCTWCE EGG GradeGastroparesis1UGE2122Yes2142–4Yes2Not DoneNot DoneNot DoneNot Done272–3No3UGE/LGE301–4Yes552–4No4LGE682–4Yes993–4Yes5UGE/LGE5892Yes5933Yes6UGE/LGE374Yes333–4Yes7UGE/LGE2042–4Yes1703–4No8LGE152–3Yes183–4No9UGE/LGE222Yes323–4No10UGE/LGE163Yes1612Yes11UGE/LGE1601–2Yes1614No11Not RepeatedNot RepeatedNot RepeatedYes1953–4No

A prospective study of the utility of abdominal radiographs after capsule endoscopy for the diagnosis of capsule retention

Capsule retention is a rare but serious complication of capsule endoscopy (CE). The utility of routine abdominal radiographs after CE for the diagnosis of capsule retention is not established. To establish the utility of abdominal radiographs in the diagnosis of capsule retention in patients undergoing CE. Prospective cohort study. Consecutive patients undergoing CE. Mayo Clinic Scottsdale, Arizona, a multispecialty academic medical center. Abdominal radiographs were performed on days 3, 7, and 14 after CE. If the patient visualized passage of the capsule, the subsequent abdominal radiograph was cancelled. Capsule retention, defined as the capsule endoscope seen on the day-14 abdominal radiograph. A total of 115 patients (46% men; mean age 65 years, range 20-88 years) underwent CE, which was performed for obscure GI bleeding in 86%, for suspected Crohn's disease in 5%, and for other indications in 9%. Thirty-four patients (30%) reported spontaneous passage of the capsule by day 3 and an additional 2 patients by day 7. Of the 81 reporting nonpassage by day 3, 66 (82%) underwent abdominal radiographs. Abdominal radiographs in 14 of 66 patients (21%), 3 of 12 (25%), and 2 of 3 (66%) showed a retained capsule on day 3, 7, and 14, respectively. Three patients (2.6%) were diagnosed with capsule retention. Two had serial abdominal radiographs: capsule retention was detected on the day-14 radiographs, and both underwent surgery. Histopathology revealed diaphragm disease of the small intestine in both patients. One patient who did not have serial abdominal radiographs had a small-bowel tumor as the cause of his capsule retention. In all 3 patients, the colon was not visualized on CE. Capsule retention is a rare but serious complication of CE. Most patients do not visualize capsule passage. For patients who do not visualize capsule passage and, in whom the colon is not visualized on the video imaging, an abdominal radiograph on day 14 will help identify those with capsule retention.

Clinical Utility of the RAPID Access RT for Real-Time Viewing of Capsule Endoscopy

Introduction: The utility of capsule endoscopy (CE) is well established for the detection of small bowel disease. The current protocol allows the ingestion of liquids 2 hours and food 4 hours after ingestion of the PillCam SB, based on studies reporting an average gastric transit time of 1 hour. However, gastric transit times can be prolonged, resulting in contamination of luminal contents with food residue that can impair visibility. Aim: To evaluate the clinical utility of real-time viewing of capsule endoscopy images using the RAPID Access RT (Given Imaging) to determine if the PillCam SB had entered the small bowel. Material and Methods: During capsule endoscopy, real-time images were viewed at 60, 90 and 120 minutes to determine if the small bowel (SB) had been entered. If the capsule had reached the SB the patient's diet was immediately advanced to light meals. If the capsule was found to be retained in the stomach at 90 minutes, 10 mg of metoclopramide were administered to facilitate passage into the small bowel. If the capsule was found to be retained in the stomach at 120 minutes, the patient was referred for endoscopic SB placement of the capsule. Results: 20 patients (8M/12F; mean age 55) were studied. RAPID Access RT acquisition of real-time images was successful in all patients. The image quality was found to be excellent. The capsule had reached the SB after 60 minutes in 11 patients. The time to reach the cecum was less than 4 hours in 8 patients (40%) and less than 6 hours in an additional 5 patients (65%). The capsule remained in the stomach after 120 minutes in 3 patients who were then referred for endoscopy-assisted placement in the SB. In 2 patients the capsule passed spontaneously into the SB before upper endoscopy could be performed. The third patient refused to undergo upper endoscopy. The capsule reached the cecum in only one of the three patients with delayed gastric passage. Conclusions: The RAPID Access RT system enabled real-time viewing of CE images in all patients. Oral intake was appropriately started after the capsule reached the small bowel. Documentation of passage into the SB at 60 minutes allowed early advancement of oral intake. This may have particular utility in patients requiring medication. Documentation of delayed gastric passage at 90 and 120 minutes allowed the institution of measures to facilitate capsule passage into the small bowel.

What we have learned from 5 cases of permanent capsule retention

Capsule endoscopy allows the direct visualization of the entire small bowel. There is limited data on the clinical significance of permanent capsule retention. Our purpose was to document the frequency, findings, risk factors, management, and outcomes of permanent capsule retention. Retrospective, case series. Single tertiary referral center, outpatient. Permanent capsule retention occurred in 2% of our cases (5/245). The following pathologies caused insufficient capsule passage: adenocarcinoma in a patient with hereditary nonpolyposis colorectal cancer (1), idiopathic stenosis (1), stricturing Crohn's disease (2), and adhesions (1). Capsule retention lead to a symptomatic small-bowel obstruction in only 1 of these cases (0.4%). As a consequence, 2 cases had successful endoscopic retrieval; 3 cases required surgical intervention. Four of 5 patients had a clear clinical benefit resulting from the capsule findings or the secondary procedure. Permanent capsule retention is rare. Even though this event may lead to the necessity of an endoscopic or surgical intervention, a clear benefit for the patient in respect to the underlying disease resulted in 4 of 5 patients.

Can the Small-Bowel Transit Time Influence the Diagnostic Yields of Capsule Endoscopy?

Background: To improve the small-bowel transit of capsule endoscopy recently, various preparations or probiotics are being used, but it is not well known how these methods can influence on diagnostic yields. However, if the small-bowel transit is fast, it is concerned that missing rate is increased. The aim of this study was whether diffenrentiation in the diagnostic yields is shown according to small bowel transit times. Methods: A total of 80 patients with gastrointestinal bleeding in whom the capsule endoscopy produced views of the cecum were assessed after negative upper and lower endoscopy. These findings such as multiple angioectasias, actively bleeding lesions, ulcers, and tumors were classified as positive. Capsule transit times through the small bowel were evaluated by analysis of the videos generated during the capsule's passage. The mean small-bowel transit time for all patient was 289.5 ± 96.2 minutes. The patients were divided into two groups: faster than mean transit time (Group I, n = 38) and slower than mean transit time (Group II, n = 42). Results: The small-bowel transit times were 209.8 ± 62.8 minutes in group I and 361.6 ± 55.3 minutes in group II. Diagnostic yields were 62.5% in both groups, 55.3% in group I, and 69.1% in group II (p = 0.25). Conclusions: The diagnostic yields of capsule endoscopy showed no statistically significant differences in two groups. But, there was a trend that the diagnostic yields of capsule endoscopy was higher for group II than group I.