Colon capsule endoscopy for inflammatory bowel disease

Colon capsule endoscopy (CCE) is designed for direct visualization of the colonic mucosa through passive propulsion. The role of CCE in the detection of colonic polyps has been extensively evaluated. As mucosal healing has emerged as a pivotal target for treatment of inflammatory bowel disease (IBD), there is increasing data to suggest that CCE can also be used in the monitoring of mucosal inflammation in patients with active IBD, particularly in ulcerative colitis (UC) and Crohn's disease (CD). Despite advantages such as its non‐invasive nature, patient's comfort, safety, and access to anatomical regions not easily reached by conventional endoscopy, CE has limitations including the lack of ability to obtain biopsies or therapeutic capabilities and no control over movement. In this review, the role and diagnostic value of CCE on diagnosis and monitoring of UC and CD patients, its safety and limitations are discussed.     

Capsule endoscopy in Crohn’s disease: Are we seeing any better?

Crohn’s disease (CD) is a complex, immune-mediated disorder that often requires a multi-modality approach for optimal diagnosis and management. While traditional methods include ileocolonoscopy and radiologic modalities, increasingly, capsule endoscopy (CE) has been incorporated into the algorithm for both the diagnosis and monitoring of CD. Multiple studies have examined the utility of this emerging technology in the management of CD, and have compared it to other available modalities. CE offers a noninvasive approach to evaluate areas of the small bowel that are difficult to reach with traditional endoscopy. Furthermore, CE maybe favored in specific sub segments of patients with inflammatory bowel disease (IBD), such as those with IBD unclassified (IBD-U), pediatric patients and patients with CD who have previously undergone surgery.     

Capsule endoscopy:Present status and future expectation

Video capsule endoscopy(CE)since its introduction 13years back,has revolutionized our approach to small intestinal diseases.Obscure gastrointestinal bleed(OGIB)continues to be the most important indication for CE with a high sensitivity,specificity as well as positive and negative predictive values.It is best performed during ongoing bleed or immediately thereafter.Overt OGIB has a higher diagnostic yield than occult OGIB.However,even in iron deficiency anemia,CE is emerging as important investigation after initial negative work up.In suspected Crohn’s disease(CD),CE has been shown superior to traditional imaging and endoscopic technique and should be considered after a negative ileocolonoscopy.Although CE has also been used for evaluating established CD,a high capsule retention rate precludes its use ahead of cross-sectional imaging.Celiac disease,particularly where gastro-duodenoscopy cannot be performed or is normal,can also be investigated by CE.Small bowel tumor,hereditary polyposis syndrome,and non-steroidal anti-inflammatory drugs induced intestinal damage are other indications for CE.Capsule retention is the only significant adverse outcome of CE and occurs mostly in presence of intestinal obstruction.This can be prevented by use of Patency capsule prior to CE examination.Presence of cardiac pacemaker and intracardiac devices continue to be relative contraindications for CE,though data do not suggest interference of CE with these devices.Major limitations of CE today include failure to control its movement from outside,inability of CE to acquire tissue for diagnosis,and lack of therapeutic help.With ongoing interesting and exciting developments taking place in these areas,these issues would be solved in all probability in near future.CE has the potential to become one of the most important tools in diagnostic and possibly in the therapeutic field of gastrointestinal disorder.     

Evaluation of the small bowel in inflammatory bowel disease

Crohn’s disease is a chronic inflammatory bowel disease (IBD) that can affect the entire GI tract, and adequate visualization of the small bowel is imperative for both diagnosis and management. Magnetic resonance and computed tomography enterography have gradually replaced barium-based studies. Magnetic resonance enterography has the distinct advantage of avoiding ionizing radiation to which many patients with IBD are overexposed. Endoscopy-based techniques, including capsule endoscopy and device-assisted enteroscopy, allow direct visualization of the small bowel mucosa. Deep enteroscopy has the additional benefit of allowing sampling of the mucosa for histological analysis. Small intestine contrast ultrasound is rapidly gaining credence as an excellent, radiation-free imaging technique, but is not available in all countries. Other imaging modalities, such as positron emission tomography and leucocyte scintigraphy, continue to be studied and may have a role in specific circumstances. This review summarizes the evidence for the various techniques for evaluating the small bowel in IBD.     

Role of capsule endoscopy in inflammatory bowel disease

Videocapsule endoscopy(VCE) has revolutionized our ability to visualize the small bowel mucosa. This modality is a valuable tool for the diagnosis of obscure small bowel Crohn’s disease(CD), and can also be used for monitoring of disease activity in patients with established small-bowel CD, detection of complications such as obscure bleeding and neoplasms, evaluation of response to anti-inflammatory treatment and postoperative recurrence following small bowel resection. VCE could also be an important tool in the management of patients with unclassified inflammatory bowel disease, potentially resulting in reclassification of these patients as having CD. Reports on postoperative monitoring and evaluation of patients with ileal pouch-anal anastomosis who have developed pouchitis have recenty been published. Monitoring of colonic inflammatory activity in patients with ulcerative colitis using the recently developed colonic capsule has also been reported. Capsule endoscopy is associated with an excellent safety profile. Although retention risk is increased in patients with small bowel CD, this risk can be significanty decreased by a routine utilization of a dissolvable patency capsule preceding the ingestion of the diagnostic capsule. This paper contains an overview of the current and future clinical applications of capsule endoscopy in inflammatory bowel disease.     

Capsule endoscopic features of Crohn's disease

Background: Crohn's disease (CD) is becoming increasingly recognized in Indian patients. As this disease often affects the small bowel, capsule endoscopy can help diagnose this disease and add valuable information regarding the extent of the disease. Our aim is to report our experience with the wireless capsule endoscope in patients with either known or suspected CD. Methods: Patients referred for capsule endoscopy with known or suspected CD were studied. All patients underwent precapsule endoscopy colonoscopy and small bowel series examination. After an overnight fast and bowel preparation, the capsule was ingested and the data were recorded for 8 h on the external recording device. A gastroenterologist experienced in reading capsule endoscopy interpreted images. Results: Eleven patients (mean age 42 years [range 14–70], 7 males) underwent capsule examination. Seven patients had symptoms suggestive of CD with no precapsule evidence of the disease, one had suspected small bowel pseudo‐obstruction and three had known CD. All patients had lesions in the small intestine consistent with CD. Two patients had strictures that led to a retained capsule, despite precapsule small bowel series. Conclusions: Capsule endoscopy is emerging as a small bowel imaging modality that can greatly assist in making the diagnosis of CD. Small bowel radiology is unreliable in excluding strictures that may cause capsule retention.     

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 CCE as 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.     

Capsule endoscopy: past,present, and future

A capsule endoscope is a swallowable wireless miniature camera for getting images of the gastrointestinal (GI) mucosa. The initial capsule endoscope model was developed by Given Imaging and approved in Western countries in 2001. Before the introduction of capsule endoscopy (CE) and double-balloon endoscopy (DBE), there was no effective modality for the evaluation and management of patients with obscure GI bleeding. Obscure GI bleeding is defined as bleeding of unknown origin that persists or recurs after a negative initial or primary endoscopy (colonoscopy or upper endoscopy) result. The first capsule endoscope model, which is now regarded as a first-line tool for the detection of abnormalities of the small bowel, was the PillCam SB. It was approved in Japan in April 2007. The main indication for use of the PillCam SB is obscure GI bleeding. Almost the only complication of CE is capsule retention, which is the capsule remaining in the digestive tract for a minimum of 2 weeks. A retained capsule can be retrieved by DBE. There are some limitations of CE in that it cannot be used to obtain a biopsy specimen or for endoscopic treatment. However, the combination of a PillCam SB and DBE seems to be the best strategy for management of obscure GI bleeding. Recently, several new types of capsule endoscope have been developed, such as Olympus CE for the small bowel, PillCam ESO for investigation of esophageal diseases, and PillCam COLON for detection of colonic neoplasias. In the near future, CE is expected to have a positive impact on many aspects of GI disease evaluation and management.     

Diagnostic yield of capsule endoscopy versus magnetic resonance enterography and small bowel contrast ultrasound in the evaluation of small bowel Crohn’s disease: Systematic review and meta-analysis

Background and aimsCapsule endoscopy (CE), magnetic resonance enterography (MRE) and small bowel (SB) intestinal contrast ultrasound (SICUS) are the modalities of choice for SB evaluation. This study aimed to compare the diagnostic yield (DY) of CE to MRE and SICUS in detection and monitoring of SB CD through meta-analysis of the available literature.MethodsWe performed a systematic literature search for trials comparing the accuracy of CE, MRE and SICUS for detection of active SB inflammation in patients with suspected and/or established CD. Only prospective studies comparing CE with another additional diagnostic modality were included in the final analysis. Pooled odds ratios (ORs) for the DY of the three modalities were calculated.ResultsA total of 112 studies were retrieved; following selection, 13 studies were eligible for analysis. The DY of CE for detection of active SB CD was similar to that of MRE (10 studies, 400 patients, OR 1.17; 95% CI 0.83–1.67) and SICUS (5 studies, 142 patients, OR 0.88; 95% CI 0.51–1.53). The outcomes were similar for the subgroups of suspected versus established CD and adult versus pediatric patients. CE was superior to MRE for proximal SB CD (7 studies, 251 patients, OR 2.79; 95% CI 1.2–6.48); the difference vs SICUS was not significant.ConclusionCE, MRE and SICUS have similar DY for detection of SB CD in both suspected and established CD. CE is superior to MRE for detection of proximal SB disease, however the risk of capsule retention should be considered.     

Capsule endoscopy:Current practice and future directions

Capsule endoscopy(CE)has transformed investigation of the small bowel providing a non-invasive,well tolerated means of accurately visualising the distal duodenum,jejunum and ileum.Since the introduction of small bowel CE thirteen years ago a high volume of literature on indications,diagnostic yields and safety profile has been presented.Inclusion in national and international guidelines has placed small bowel capsule endoscopy at the forefront of investigation into suspected diseases of the small bowel.Most commonly,small bowel CE is used in patients with suspected bleeding or to identify evidence of active Crohn’s disease(CD)(in patients with or without a prior history of CD).Typically,CE is undertaken after upper and lower gastrointestinal flexible endoscopy has failed to identify a diagnosis.Small bowel radiology or a patency capsule test should be considered prior to CE in those at high risk of strictures(such as patients known to have CD or presenting with obstructive symptoms)to reduce the risk of capsule retention.CE also has a role in patients with coeliac disease,suspected small bowel tumours and other small bowel disorders.Since the advent of small bowel CE,dedicated oesophageal and colon capsule endoscopes have expanded the fields of application to include the investigation of upper and lower gastrointestinal disorders.Oesophageal CE may be used to diagnose oesophagitis,Barrett’s oesophagus and varices but reliability in identifying gastroduodenal pathology is unknown and it does not have biopsy capability.Colon CE provides an alternative to conventional colonoscopy for symptomatic patients,while a possible role in colorectal cancer screening is a fascinating prospect.Current research is already addressing the possibility of controlling capsule movement and developing capsules which allow tissue sampling and the administration of therapy.     

Small bowel video capsule endoscopy in Crohn’s disease: What have we learned in the last ten years?

Since its introduction in 2001, capsule endoscopy (CE) has become the most important advance in the study of small bowel disease, including Crohn’s disease (CD). This technique has been demonstrated to be superior to all other current forms of radiological investigation in detecting mucosal abnormalities of small bowel nonstricturing CD. CE has proven to be extremely useful in diagnosing CD in patients with inconclusive findings from ileocolonoscopy and x-ray-based studies. Almost half of all patients with CD involving the ileum also present lesions in proximal intestinal segments, with the small bowel being exclusively involved in up to 30% of all CD cases. Despite the widespread use of CE, several questions concerning the utility of this technique remain unanswered. The lack of commonly agreed diagnostic criteria for defining CD lesions with the aid of CE may have had an influence on the variation in diagnostic re sults for CE reported in the literature. The utility of CE in monitoring CD and in guiding therapy has also been proposed. Furthermore, CE could be a useful second-line technique for patients with an established diagn osis of CD and unexplained symptoms. Finally, as no thres hold for CD diagnosis has been agreed upon, a se verity scale of mucosal disease activity has notbeen universally followed. None of the available activity indexes based on CE findings has been independently validated. This article discusses several cutting-edge aspects of the usefulness of CE in CD 10 years after its introduction as a sensible method to study the small intestine.     

Endoscopic assessment of inflammatory bowel disease: colonoscopy/esophagogastroduodenoscopy

Endoscopy plays an important role in the initial diagnosis of IBD, including the evaluation of disease severity, activity, and extent. The implications of complete mucosal healing further confirm the function of endoscopy in the follow-up of IBD patients. The use of therapeutic endoscopy, for example stricture dilatation, can avoid the need for bowel resection. Modalities such as capsule endoscopy, EUS, NBI, CE, and other emerging techniques are likely to have an increasing role in the management of IBD, particularly in the area of dysplasia surveillance and treatment.     

Capsule endoscopy: a comprehensive review

The development of wireless capsule endoscopy (CE) has been a significant technologic advancement for the non-invasive visual evaluation of the entire small bowel and esophagus. The capsule endoscope is disposable and measures 11 x 26 mm. There are two capsule endoscopes currently available: PillCam ESO and PillCam SB for the evaluation of the esophagus and the small bowel, respectively. The PillCam ESO has two cameras on each end and captures images 7 frames per second per each camera, while the PillCam SB has one camera and captures images at a rate of 2 frames per second. Both capsule endoscopes transmit the image data using a radiofrequency signal to a recording device worn on the patient's waist. Once image acquisition is completed, the data from the recording device is downloaded to a computer workstation and analyzed by a gastroenterologist. Common indications for the small bowel CE include obscure gastrointestinal bleeding (OGIB), suspected Crohn disease (CD), as well as other suspected small bowel pathologies, while indications for the esophageal CE include screening of Barrett esophagus and esophageal varices. Small bowel CE appears to be more sensitive in the evaluation of OGIB and small bowel CD compared with other conventional radiological and endoscopic modalities. Preliminary results for the esophageal CE reveal good accuracy for screening of both Barrett and esophageal varices. CE is well tolerated by most patients, requires no sedation, and carries few side effects. One of the complications of CE is capsule retention; however, a patency capsule system has been developed, which can indicate whether an obstructing lesion is present before CE is performed. Finally, there are preliminary data suggesting that a new capsule endoscope for the colon may be useful in the evaluation of patients for colon polyps and possibly, screening for colon cancer.     

Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature

Iron deficiency anemia (IDA) is common and often under recognized problem in the elderly. It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract. Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel (SB). Capsule endoscopy (CE) provides direct visualization of entire SB mucosa, which was not possible before. It is superior to push enteroscopy, enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA. Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA. The diagnostic yield of CE for IDA progressively increases with advancing age, and is highest among patients over 85 years of age. Balloon assisted enteroscopy is used to treat the lesions seen on CE. CE has some limitations mainly lack of therapeutic capability, inability to provide precise location of the lesion and false positive results. Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.     

Five years' experience with capsule endoscopy in a single Center

Capsule endoscopy (CE) is a novel technology that facilitates highly effective and noninvasive imaging of the small bowel. Although its efficacy in the evaluation of obscure gastrointestinal bleeding (OGIB) has been proven in several trials, data on uses of CE in different small bowel diseases are rapidly accumulating in the literature, and it has been found to be superior to alternative diagnostic tools in a range of such diseases.Based on literature evidence, CE is recommended as a first-line investigation for OGIB after negative bidirectional endoscopy. CE has gained an important role in the diagnosis and follow-up of Crohn's disease and celiac disease and in the surveillance of small bowel tumors and polyps in selected patients. Capsule retention is the major complication, with a frequency of 1%-2%. The purpose of this review was to discuss the procedure, indications, contraindications and adverse effects associated with CE. We also review and share our five-year experience with CE in various small bowel diseases. The recently developed balloon-assisted enteroscopies have both diagnostic and therapeutic capability. At the present time, CE and balloon-assisted enteroscopies are complementary techniques in the diagnosis and management of small bowel diseases.     

TNF-α在IBD发病机制中的调节

炎症性肠病（inflammatory bowel disease,IBD）是一种病因不明的肠道非特异性炎症性疾病,包括溃疡性结肠炎和克罗恩病,它们有各自的临床特征,内镜表现和组织学可区分;有学者认为它们是同一疾病的两个不同的阶段。在免疫应答中,TNF-α（TNF核心家族成员之一）作为细胞增殖和凋亡的主要促炎因子,在IBD的发病机制中起重要的调节作用。     

Clinical application of video capsule endoscopy

BACKGROUND: Non-invasive imaging of the complete small bowel has become possible with the recently available video capsule endoscopy technique. The aim of this study was to review and assess the possibilities and limitations of the clinical application of video capsule endoscopy. METHODS: Literature review. RESULTS: Video capsule endoscopy is a new promising technique with good to excellent visualization of the mucosa of the small bowel. It has a high diagnostic yield in patients with occult gastrointestinal blood loss (OGIB) and Crohn disease (CD). Several other indications need further study. Compared to small-bowel X-ray and push enteroscopy, diagnostic yield appears to be superior. Video capsule endoscopy is very well tolerated by patients. Its most important limitation is the impossibility of taking biopsies and therapeutic interventions. CONCLUSION: Video capsule endoscopy is a promising new diagnostic tool for small-bowel disease.     

Klinik, CRP, Calprotectin, MRT oder Endoskopie?

Close monitoring of the therapeutic efficacy and inflammation in inflammatory bowel diseases (IBD) is important in order to improve outcome and realize individualized treatment. As a symptom-based evaluation only has several limitations more objective tools are necessary. In this aspect C-reactive protein (CRP) especially in Crohn’s disease (CD) and fecal markers, such as calprotectin in both CD and ulcerative colitis (UC) have been shown to be associated with the inflammatory burden and endoscopic activity. Furthermore, they correlate well with treatment response and can be used in order to make a better prediction of disease relapse. Endoscopic evaluation is, however, still often necessary especially for important decisions on either treatment intensification or de-escalation. During therapy CRP and fecal markers can be used to evaluate efficacy and often make endoscopic interventions unnecessary. Ultrasound, magnetic resonance imaging (MRI) and capsule endoscopy are less well evaluated and are reserved for solitary cases. In summary, CRP, fecal calprotectin in addition to endoscopy represent important tools in order to optimize IBD treatment.     

Inflammatory bowel disease imaging: current practice and future directions

The purpose of this paper is to evaluate the role of imaging in inflammatory bowel disease(IBD), including detection of extraluminal complications and extraintestinal manifestations of IBD, assessment of disease activity and treatment response, and discrimination of inflammatory from fibrotic strictures. IBD is a chronic idiopathic disease affecting the gastrointestinal tract that is comprised of two separate, but related intestinal disorders; Crohn's disease and ulcerative colitis. The paper discusses, in detail the pros and cons of the different IBD imaging modalities that need to be considered in order to optimize the imaging and clinical evaluation of patients with IBD. Historically, IBD evaluation of the bowel has included imaging to assess the portions of the small bowel that are inaccessible to optical endoscopic visualization. This traditionally was performed using barium fluoroscopic techniques; however, cross-sectional imaging techniques(computed tomography and magnetic resonance imaging) are being increasingly utilized for IBD evaluation because they can simultaneously assess mural and extramural IBD manifestations. Recent advances in imaging technology, that continue to improve the ability of imaging to noninvasively follow disease activity and treatment response, are also discussed. This review article summarizes the current imaging approach in inflammatory bowel disease as well as the role of emerging imaging modalities.     

Klinik,CRP, Calprotectin,MRT oder Endoskopie?

Close monitoring of the therapeutic efficacy and inflammation in inflammatory bowel diseases (IBD) is important in order to improve outcome and realize individualized treatment. As a symptom-based evaluation only has several limitations more objective tools are necessary. In this aspect C-reactive protein (CRP) especially in Crohn’s disease (CD) and fecal markers, such as calprotectin in both CD and ulcerative colitis (UC) have been shown to be associated with the inflammatory burden and endoscopic activity. Furthermore, they correlate well with treatment response and can be used in order to make a better prediction of disease relapse. Endoscopic evaluation is, however, still often necessary especially for important decisions on either treatment intensification or de-escalation. During therapy CRP and fecal markers can be used to evaluate efficacy and often make endoscopic interventions unnecessary. Ultrasound, magnetic resonance imaging (MRI) and capsule endoscopy are less well evaluated and are reserved for solitary cases. In summary, CRP, fecal calprotectin in addition to endoscopy represent important tools in order to optimize IBD treatment.