Indications For Small Bowel Capsule Endoscopy Research Articles

Small-Bowel Capsule Endoscopy: Indications and Results in Endoscopy Unit

Small-bowel capsule endoscopy (SBCE) is used widely because of its non-invasive and patient-friendly nature. SBCE can visualize entire small-intestinal mucosa and facilitate detection of small-intestinal abnormalities. Indications for SBCE are obscure gastrointestinal bleeding, Crohn’s disease, small-intestinal polyps, tumors and celiac disease. Materials and methods: We report a study from September 2018 to February 2022, including 59 patients who underwent SBCE type PillCam SB3®. All our patients previously had a normal endoscopic assessment (oesogastro-duodenal fibroscopy and ileo-colonoscopy). CT enterography and MR enterography realized in 54.2% of cases were normal. The preparation used is PEG (2l the day before and 0.5l after ingesting the capsule) with clear broth the day before the examination and 10 days off oral iron if taken. Results: The mean age was 53.9 years, with a female predominance (sex ratio: 0.52). 16.9% of the patients had a history of heart disease, 8.4% are chronic renal failure, 5% are followed for Crohn's disease and 3.3% for celiac disease. 10.1% of patients were on anticoagulants and 5% on antiplatelet agents. The indication for SBCE was Obscure gastrointestinal bleeding (OGIB) in 86,3%, Crohn's disease (CD) in 5%, celiac disease in 3,3%, chronic diarrhea in 3,3%, and unexplained edematoascites syndrome in 1,6%. SBCE found small bowel angiodysplasia lesions in 40.6% of patients, small bowel inflammatory lesions in 15% of patients, a submucosal tumor appearance in 6.7% of patients and active small bowel bleeding in 5% patients. The examination did not objectivate small bowel lesion in 25.4% of patients. Non-small bowel lesions have been demonstrated in the form of gastric (16.9% of cases) and cecal (10.1% of cases) angiodysplasia responsible for OGIB. Conclusion: In our study, SBCE showed lesions in 74,6% of cases; dominated by angiodysplasia followed by inflammatory lesions and submucosal tumors and whose indication was essentially OGIB. Enteroscopy with biopsies or with therapeutic gesture, remains essential in the management of these patients.

RHEMITT Score Predicts Rebleed After Capsule Endoscopy: First Validation at a U.S. Tertiary Care Center.

Patients with obscure gastrointestinal bleeding undergo small bowel capsule endoscopy (SBCE), but often return for recurrent bleeding or anemia. The RHEMITT score evaluates patients based on 7 variables (heart failure, chronic kidney disease, Saurin P1/P2 lesions, major bleeding, incomplete SBCE, smoking status, and endoscopic treatment) and seeks to predict the risk of rebleeding. This study aims to perform an external validation of the RHEMITT score in the United States. SBCEs performed to evaluate anemia or GI bleeding from a tertiary-care center's PillCam database between 1/22/2018 and 7/21/2020 were reviewed. Variables based on the RHEMITT score were collected. The primary outcome was rebleeding, defined as (1) melena or hematochezia or (2) hemoglobin drop of 2g/dL. Patient were categorized into low, intermediate, and high-risk categories based on RHEMITT score. The accuracy of the RHEMITT score for predicting rebleeding was assessed. A total of 361 SBCEs were included in the study. Age, indication for SBCE, endoscopic treatment, antiplatelet use, cirrhosis, heart failure, chronic kidney disease, and major bleeding were significantly associated with risk of rebleed (p < 0.05). Each increasing risk category for the RHEMITT score predicted increased probability of this study's primary outcome, rebleeding (p < 0.001). There was a significant association between RHEMITT risk category and rebleeding-free survival (log-rank p < 0.001). An area under the receiver operating characteristic curve for the RHEMITT score was 0.790 (p < 0.001). Our findings validate the RHEMITT score and confirm acceptable performance for predicting rebleeding at a tertiary referral center in the United States.

Diagnostic yield of small bowel capsule endoscopy in obscure gastrointestinal bleeding: a real-world prospective study

Small bowel capsule endoscopy (SBCE) visualizes the small bowel (SB) mucosa. Gastrointestinal (GI) bleeding from SB accounts for the majority of SBCE indications. We aimed to assess, in a “real-world” prospective study, the diagnostic yield of SBCE in a cohort of consecutive patients with obscure gastrointestinal bleeding (OGIB). Secondary end point was to assess the frequency of adverse events and the role of SBCE in determining the diagnostic work-up and clinical outcome. From 2016 to 2018, all patients referred for SBCE examination were enrolled. Indication for SBCE was re-assessed by 2 dedicated gastroenterologists. Inclusion criteria: (1) age ≥ 18 and ≤ 85 years; (2) diagnosis of OGIB; 3) non-diagnostic standard bidirectional endoscopy; (4) informed consent. Exclusion criteria: (1) deglutition impairment; (2) SBCE contraindications; (3) pregnancy. The cohort included 50 patients [males 18 (36%), age 68 (27–83)]. SBCE indication: patients with ongoing overt OGIB (Group A) (n = 11; 22%), previous overt OGIB (Group B) (n = 14; 28%), occult bleeding (with Iron Deficiency Anaemia) (Group C) (n = 25; 50%). SBCE detected clinically relevant lesions in 46 (92%) cases. Clinically relevant lesions were more frequent in Group C (24/25; 96%), followed by Group A (10/11; 91%) and Group B (12/14; 85.5%). After SBCE, treatment was medical (60%); endoscopic (14%), surgical (36%) or conservative (18%). Clinical follow-up showed complete resolution in 63.2%, partial/absent resolution in 18.4% of cases. In a prospective study, the high diagnostic yield of SBCE supports its role as first-line investigation in patients with OGIB. However, this achievement requires an accurate and timely assessment by dedicated gastroenterologists.

Assessment of the Role of a Second Evaluation of Capsule Endoscopy Recordings to Improve Diagnostic Yield and Patient Management

Introduction: The diagnostic yield (DY) of small-bowel capsule endoscopy (SBCE) varies considerably according to its indication. Some strategies have been used to increase DY with varying results. The intention of this study was to identify whether evaluation of the SBCE recordings by a second reviewer can increase DY and change patient management. Methods: One hundred SBCEs with different indications, already read by an endoscopist were read by a second blinded endoscopist. When the results of the 2 readings were different, the images were discussed by the endoscopists; if no consensus was reached, they took the opinion of a third endoscopist into account. All the participating endoscopists had experience in reading SBCEs (i.e., >50 per year). The SBCE findings were divided into positive (vascular lesions, ulcers, and tumors), equivocal (erosions or red spots), and negative. The interobserver agreement and the increase in DY were assessed as well as the percentage of false-negatives (FNs) in the first evaluation. Results: The indications for SBCE were small-bowel bleeding (SBB) in 48 cases, Crohn’s disease (CD) in 30, and other causes (iron-deficiency anemia, small-bowel tumors, and diarrhea) in 22. There was substantial interobserver agreement between evaluations (κ = 0.79). The findings in the first evaluation were positive in 60%, equivocal in 20% and, negative in 20%. In the second evaluation, 66% were positive, 18% were equivocal, and 16% were negative. The increase in DY with the second reading was 6% (p = 0.380), i.e., 6.3% for SBB, 4.4% for CD and 9.2% for other indications, resulting in a change in management of 4% of the patients. FNs in the first SBCE reading were found in 4% of the SBCEs. Discussion: A second evaluation of the SBCE recordings identified significant pathology that the first evaluation had missed, resulting in a nonsignificant 6% increase in DY and a change in the management of 4% of the patients.

Quality performance measures for small capsule endoscopy: Are the ESGE quality standards met?

Background and study aims The European Society of Gastrointestinal Endoscopy (ESGE) recently issued a quality performance measures document for small bowel capsule endoscopy (SBCE). The aim of this nationwide survey was to explore SBCE practice with ESGE quality measures as a benchmark. Patients and methods A dedicated per-center semi-quantitative questionnaire based on ESGE performance measures for SBCE was created by a group of SBCE experts. One-hundred-eighty-one centers were invited to participate and were asked to calculate performance measures for SBCE performed in 2018. Data were compared with 10 ESGE quality standards for both key and minor performance measures. Results Ninety-one centers (50.3 %) participated in the data collection. Overall in the last 5 years (2014–2018), 26,615 SBCEs were performed, 5917 of which were done in 2018. Eighty percent or more of the participating centers reached the minimum standard established by the ESGE Small Bowel Working Group (ESBWG) for four performance measures (indications for SBCE, complete small bowel evaluation, diagnostic yield and retention rate). Conversely, compliance with six minimum standards established by ESBWG concerning adequate bowel preparation, patient selection, timing of SBCE in overt bleeding, appropriate reporting, reading protocols and referral to device-assisted enteroscopy was met by only 15.5 %, 10.9 %, 31.1 %, 67.7 %, 53.4 %, and 32.2 % of centers, respectively. Conclusions The present survey shows significant variability across SBCE centers; only four (4/10: 40 %) SBCE procedural minimum standards were met by a relevant proportion of the centers ( ≥ 80 %). Our data should help in identifying target areas for quality improvement programs in SBCE.

Small bowel capsule endoscopy: where do we stand after 20 years of clinical use?

Small bowel capsule endoscopy (SBCE) was introduced into clinical practice almost 20 years ago and, nowadays, it is an essential tool for the study of the small bowel. SBCE allows a radiation-free examination of the entire mucosal surface of the small bowel with high-quality images, limited invasivity and a good safety profile. Nevertheless, the main limitation of SBCE is the lack of any possible direct therapeutic intervention. Indications for SBCE have evolved throughout the years, from "old" ones such as suspected small bowel bleeding (still the main indication for SBCE) to newer ones such as refractory celiac disease, hereditary polyposis syndromes and Crohn's disease. Thus, nowadays SBCE has a key role in the diagnostic algorithms in many conditions. Furthermore, the introduction in the SBCE field of cutting-edge technologies, as artificial intelligence systems, is likely to shorten the reading time making SBCE even more effective and easy to perform. Preliminary data are extremely promising and solid evidence is being gathered by current studies.

Capsule endoscopy for small-intestinal disorders: Current status.

Small-bowel capsule endoscopy (SBCE) is used widely because of its non-invasive and patient-friendly nature. SBCE can visualize entire small-intestinal mucosa and facilitate detection of small-intestinal abnormalities. In this review article, we focus on the current status of SBCE. Several platforms for SBCE are available worldwide. Third-generation SBCE (PillCam® SB3) has a high-resolution camera equipped with an adaptive frame rate system. Several software modes have been developed to reduce the reading time for capsule endoscopy and to minimize the possibility of missing lesions. The main complication of SBCE is capsule retention. Thus, the main contraindication for SBCE is known or suspected gastrointestinal obstruction unless intestinal patency is proven. Possible indications for SBCE are obscure gastrointestinal bleeding, Crohn's disease, small-intestinal polyps and tumors, and celiac disease. Colon capsule endoscopy (CCE) can observe inflamed colonic mucosa non-invasively, and allows for the continuous and non-invasive observation of the entire intestinal tract (pan-endoscopy). Recently, application of CCEas pan-enteric endoscopy for inflammatory bowel diseases (including Crohn's disease) has been reported. In the near future, reading for CE will be assisted by artificial intelligence, and reading CE videos for long periods will not be required.

Evaluation of Small-Bowel Patency in Crohn’s Disease: Prospective Study with a Patency Capsule and Computed Tomography

Background and Purpose: Patency capsule (PC) examination is usually performed – previously to capsule endoscopy – to evaluate small-bowel patency in patients with established Crohn’s disease (CD). The reported PC retention rate is significantly higher than expected. Our aims were to assess small-bowel patency, to determine the precise location of the retained PC in patients with CD, and to determine the false positive rate of evaluation with a radiofrequency identification tag (RFIT) scanner. Methods: This is a prospective single-center study including CD patients with clinical indication for small-bowel capsule endoscopy. PillCam® PC examination was performed on all patients to assess small-bowel patency. On all patients with a positive identification of the PC using an RFIT scanner, 30 h after ingestion, an abdominal CT was performed in order to identify its precise location. Results: Fifty-four patients were included. The PC retention rate, according to evaluation with the RFIT scanner, was 20% (in 11 patients) 30 h after ingestion. These patients were then submitted to abdominal CT, which revealed that there was small-bowel retention in 5 cases (9%). Higher CRP levels, penetrating disease, and a history of abdominal surgery were associated with an increased risk of PC retention (p = 0.007, p = 0.011, and p = 0.033, respectively). On multivariate analysis, there was an independent association between small-bowel PC retention and CRP levels >5 mg/dL (OR = 15.5; p = 0.03). Discussion: The small-bowel PC retention rate (9%) was considerably lower than those found in previous reports. Our results show that, with this protocol, the false-positive cases of RFIT scans or plain abdominal X-rays may be avoided. This may contribute to more extensive application of capsule endoscopy without the risk of small-bowel retention.

P290 Determination of small-bowel patency in Crohn’s disease - a prospective study

Patency capsule (PC) is usually performed to establish small-bowel patency, previously to capsule endoscopy (CE), in patients with an increased risk of CE retention. Notably, the reported patency capsule retention rate is significantly higher than the expected for Crohn’s disease (CD). Our aims were to assess small-bowel patency in CD patients, to determine the precise location of the retained PC, as well as to evaluate predictive factors for PC retention. Prospective single-centre study including CD patients with indication for small-bowel CE, between December 2015 and February 2017. PillCam® patency capsule was performed in all patients to access small-bowel patency; PC was ingested, after a 12-h fasting period, without previous bowel preparation. In all patients with a positive radiofrequency identification tag (RFIT) scanner identification of the PC, at 30 h after ingestion, an abdominal-CT was performed in order to determine its precise location. Fifty-four patients were included. 65% of patients were female and the mean age was 40.5 ± 11.1 years. Twelve (22%) patients had a known or suspected small-bowel stenosis detected by previous ileocolonoscopy or abdominal imaging. Twelve (22%) patients had a history of abdominal surgery (intestinal resection: n = 7). The PC retention rate at 30 h was 20% (11 patients). These patients were then submitted to abdominal-CT, which revealed a small-bowel retention only in 5 (9%) cases. Higher CRP levels, penetrating disease and a history of abdominal surgery were associated with increased risk of PC retention (p = 0.007, p = 0.011 and p = 0.033, respectively). On multivariate analysis, there was an independent association between small-bowel patency capsule retention and CRP levels >5mg/dL (OR = 15.5; p = 0.03). The PC small-bowel retention rate in CD was 9%, and even higher in patients with increased CRP levels. Our results show that, with this sequential CT protocol, the false positive cases of RFIT scanner or plain abdominal X-ray may be avoided. This may contribute to a more effective application of CE without the risk of small-bowel retention.

Indications for Small-bowel Capsule Endoscopy in Patients with Chronic Abdominal Pain.

Objective The aim of the present study is to assess the difference in the detection rates of small-bowel lesions in chronic abdominal pain (CAP) patients with irritable bowel syndrome (IBS) and non-IBS. Patients Ninety-nine CAP patients who were scheduled to undergo capsule endoscopy (CE) to investigate their abdominal symptoms were included in this study. Among the subjects, 34 patients fulfilled the Rome III criteria for IBS (IBS group); the remaining 65 patients were categorized as the non-IBS group. CE was performed in both groups and the total enteroscopy achievement rate, small-bowel lesion detection rate, and the presence of small-bowel lesions were evaluated. We also evaluated the patients' blood test results and the rate at which abdominal symptoms improved following internal medication. Results Total enteroscopy was achieved in 62% (21/34) and 86% (56/65) of the IBS and non-IBS patients, respectively. The total enteroscopy achievement rate was significantly higher in non-IBS patients. The small-bowel lesion detection rates were 3% (1/34) and 19% (12/65), respectively, and the detection rate was significantly higher in the non-IBS patients. In the non-IBS patients, mean C-reactive protein (CRP) was significantly higher in the patients with small-bowel lesions. The abdominal symptoms of 12 (92%) of the CAP patients with small-bowel lesions were improved by internal medication. Conclusion CE may be considered for non-IBS CAP patients with high levels of CRP.

Current status and future perspectives of capsule endoscopy.

Small bowel capsule endoscopy (CE) was first introduced 15 years ago, and a large amount of literature has since been produced, focused on its indication, diagnostic yields, and safety. Guidelines that have made CE the primary diagnostic tool for small bowel disease have been created. Since its initial use in the small bowel, CE has been used for the esophagus, stomach, and colon. The primary indications for small bowel CE are obscure gastrointestinal bleeding, unexplained iron deficiency anemia, suspected Crohn's disease, small bowel tumors, nonsteroidal anti-inflammatory drug enteropathy, portal hypertensive enteropathy, celiac disease, etc. Colon CE provides an alternative to conventional colonoscopy, with possible use in colorectal cancer screening. Guidelines for optimal bowel preparation of CE have been suggested. The main challenges in CE are the development of new devices with the ability to provide therapy, air inflation for better visualization of the small bowel, biopsy sampling systems attached to the capsule, and the possibility of guiding and moving the capsule by an external motion controller. We review the current status and future directions of CE, and address all aspects of clinical practice, including the role of CE and long-term clinical outcomes.

PTU-017 The Use Of Small Bowel Capsule Endoscopy In The Octogenarians Group; The Edinburgh Experience

IntroductionOver the last 13 years, the clinical use of capsule endoscopy (CE) has revolutionised the investigation pathways for the small-bowel. Although non-invasive (as procedure), there are reports of capsule aspiration...

Small‐bowel capsule endoscopy in patients with gastrointestinal food allergy

Food allergy may present with a plethora of gastrointestinal and extraintestinal symptoms such as abdominal pain, diarrhea, cardiocirculatory symptoms, cutaneous reactions, or rhinitis. Macropathological lesions like lymphofollicular hyperplasia and erosive or ulcerative lesions have seldom been described in gastroscopy and colonoscopy previously. Fifteen patients presenting with unspecific abdominal symptoms in which food allergy was detected in due course were included. During the examination process, those patients showed various indications for small-bowel capsule endoscopy, such as weight loss and anemia. Fourteen (93.3%) of the 15 small-bowel capsule endoscopies could be assessed, showing nonerosive lesions such as erythema, swelling, and lymphoid hyperplasia in 8 patients (57.1%) and erosive lesions such as aphthoid lesions, erosions, and petechiae in 4 patients (28.6%) with food allergy. In 15 patients with confirmed food allergy and after exclusion of other diseases, 12 (85.7%) showed various unspecific nonerosive or erosive mucosal lesions within the small bowel, resulting, however, partially in grave consequences such as anemia. Lymphoid hyperplasia was the most prominent finding in 7 patients (50%), albeit infectious disease had been excluded. Anemia improved within 1 year after adequate antiallergic treatment.

Significant Incidental Gastric Findings on Esophageal and Small Bowel Capsule Endoscopy Studies

Purpose: To determine the prevalence of incidental gastric findings on esophageal capsule endoscopy (ECE) and small bowel capsule endoscopy (SBCE) studies. Methods: This study is a retrospective review of total of 2338 capsule endoscopy studies which were performed from February 2003 and April 2010. The indication for ECE (n=1306) was for chronic gastroesophageal reflux disease. The indications for SBCE (n=1032) were primarily for obscure gastrointestinal bleeding (OGIB) (72%), and suspected Crohn's disease (19.4%). Other indications included suspected SB tumor (4%), abnormal radiologic findings (3.3%), celiac disease (0.5%), eosinophilic gastroenteritis (0.4%), evaluation of potential bleeding before Coumadin® treatment (0.2%), lymphangiectasia (0.1%) and suspected graft-versus-host disease (0.1%). All cases were de-identified and independently reviewed by two blinded experienced gastroenterologists. Results: Gastric findings from ECE and SBCE studies are demonstrated in Table 1. In 37.6% of SBCE cases, notable gastric findings were detected. In comparison 25% of ECE cases detected abnormal gastric findings (If multiple findings in a patient were counted as one case then 29.7% of SBCE vs. 20.1% of ECE had abnormal gastric findings). The most common findings were gastric erosions in both studies (12.4% for ECE and 12.1% for SBCE). In patients with the indication of OGIB, gastric erosions were seen in 15.3%.[1422] Table 1. Gastric findings on capsule endoscopy studiesConclusion: SBCE can detect gastric pathology that may contribute to OGIB. Also, notable gastric findings were found incidentally in ECE. For patients undergoing ECE and SBCE, gastric images should be carefully reviewed due to the high prevalence of visible pathology in the stomach by video capsule endoscopy. Disclosure: Associate Professor Rome Jutabha, MD - Medical Director: Capsule Endoscopy Services Assistant Professor James Sul, MD - Capsule endoscopy reader: Capsule Endoscopy Services Kunut Kijsirichareanchai, MD - Reseach coordinator: Capsule Endoscopy Services.

Capsule Endoscopy: A Review

Capsule endoscopy (CE) is a novel technology that allows direct noninvasive visualization of the entire small intestine. CE permits a detailed examination in the ambulatory setting, allowing identification of clinically relevant lesions, and it is appealing to both patients and providers. There are two types of capsules that are currently commercially available: one specifically designed to view the small bowel and the other for the esophagus. Common indications for small bowel CE include obscure gastrointestinal bleeding, initial diagnosis of suspected Crohn's disease, and other small bowel pathology. The esophageal capsule is currently used to evaluate Barrett esophagus and esophageal varices. It is a well-tolerated procedure with relatively few complications. Although CE performance may be superior to existing technologies, its impact on clinical decision-making and patient outcomes are of even greater importance. Herein lies a review of the latest information on CE, its indications, complications, future utilities, and developing technology.