What we have learned and what to expect from capsule endoscopy

Capsule endoscopy was conceived by Gabriel Iddan and Paul Swain independently two decades ago. These applications include but are not limited to Crohn’s disease of the small bowel, occult gastrointestinal bleeding, non steroidal anti inflammatory drug induced smallbowel disease, carcinoid tumors of the small bowel,gastro intestinal stromal tumors of the small bowel andother disease affecting the small bowel. Capsule endoscopy has been compared to traditional small bowelseries, computerized tomography studies and pushenteroscopy. The diagnostic yield of capsule endoscopyhas consistently been superior in the diagnosis of smallbowel disease compared to the competing methods(small bowel series, computerized tomography, pushenteroscopy) of diagnosis. For this reason capsule en-doscopy has enjoyed a meteoric success. Image qualityhas been improved with increased number of pixels,automatic light exposure adaptation and wider angle ofview. Further applications of capsule endoscopy of other areas of the digestive tract are being explored. Theincreased transmission rate of images per second hasmade capsule endoscopy of the esophagus a realisticpossibility. Technological advances that include a double imager capsule with a nearly panoramic view of the colon and a variable frame rate adjusted to the movement of the capsule in the colon have made capsuleendoscopy of the colon feasible. The diagnostic ratefor the identification of patients with polyps equal to orlarger than 6 mm is high. Future advances in technology and biotechnology will lead to further progress.Capsule endoscopy is following the successful moderntrend in medicine that replaces invasive tests with lessinvasive methodology.     

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.     

How helpful is capsule endoscopy to surgeons？

Capsule endoscopy is a new technology that, for the first time, allows complete, non-invasive endoscopic imaging of the small bowel. The efficacy of capsule endoscopy in the diagnosis of suspected small bowel diseases has been established. Important applications for surgeons include observations of obscure gastrointestinal bleeding and small bowel neoplasms.     

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.     

Small bowel capsule endoscopy in 2007： Indications, risks and limitations

Capsule endoscopy has revoluzionized the study of the small bowel by providing a reliable method to evaluate, endoscopically, the entire small bowel. In the last six years several papers have been published exploring the possible role of this examination in different clinical conditions. At the present time capsule endoscopy is generally recommended as a third examination, after negative bidirectional endoscopy, in patients with obscure gastrointestinal bleeding. A growing body of evidence suggests also an important role for this examination in other clinical conditions such as Crohn＇s disease, celiac disease, small bowel polyposis syndromes or small bowel tumors. The main complication of this examination is the retention of the device at the site of a previously unknown small bowel stricture. However there are also some other open issues mainly due to technical limitations of this tool （which is not driven from remote control, is unable to take biopsies, to insufflate air, to suck fluids or debris and sometimes to correctly size and locate lesions）.The recently developed double balloon enteroscope, owing to its capability to explore a large part of the small bowel and to take targeted biopsies, although being invasive and time consuming, can overcome some limitations of capsule endoscopy. At the present time, in the majority of clinical conditions （i.e. obscure GI bleeding）, the winning strategy seems to be to couple these two techniques to explore the small bowel in a painless, safe and complete way （with capsule endoscopy） and to define and treat the lesions identified （with double balloon enteroscopy）.     

Bleeding Dieulafoy’s-like lesions of the gut identified by capsule endoscopy

Dieulafoy’s-like lesions (DLs-like) represent a cause of obscure gastrointestinal bleeding, enteroscopy being the main diagnostic and therapeutic procedure. Frequently, more than one enteroscopy is needed to identify the bleeding vessel. In our practice, video capsule endoscopy (VCE) identified and guided therapy in four cases of DLs-like; three of them were localized on the small bowel. We report, for the first time, a diagnosis of colonic DL-like performed by colon capsule endoscopy. Two patients presented with severe cardiovascular disorders, being hemodynamically unstable during VCE examination. Based on the VCE findings, only one invasive therapeutic procedure per patient was necessary to achieve hemostasis. VCE and enteroscopy may be regarded as complementary procedures in patients with gut DLs-like.     

Clinical utility, safety and tolerability of capsule endoscopy in urban Southeast Asian population

AIM: Capsule endoscopy has demonstrated its clinical utility in the evaluation of small bowel pathology in several Western studies. In this prospective study, we aimed to determine the clinical utility, safety and tolerability of capsule endoscopy in the evaluation of suspected small bowel disease in an urban Southeast Asian population.METHODS: We used the given (M2A) capsule endoscopy system in 16 consecutive patients with suspected small bowel pathology. In 9 patients the indication was obscure gastrointestinal bleeding, while in 6 patients it was to determine the extent of small bowel involvement in Crohn‘s disease. One patient underwent capsule endoscopy for evaluation of chronic abdominal pain. Patient‘‘s tolerabilityto the procedure was evaluated by standardized questionnaires and all patients were reviewed at one week to ensure that the capsule had been excreted without any adverse events.RESULTS: Abnormal findings were present in 8 patients (50 %). The cause of obscure gastrointestinal bleeding was determined in 5 out of 9 patients. Findings included 2 cases of angiodysplasia, 2 cases of jejunal ulcers and 1 case of both angiodysplasia and jejunal ulcer. One patient had smallbowel erosions and foci of erythema of doubtful significance. Ileal lesions were diagnosed in 2 out of 6 patients with Crohn‘‘s disease. Capsule endoscopy was well tolerated by allpatients. One patient with Crohn‘‘s disease had a complication of capsule retention due to terminal ileum stricture. Thecapsule eventually passed out spontaneously after 1 month. CONCLUSION: Our study, which represented the first Asian series, further confirms the diagnostic utility, safety and tolerability of wireless capsule endoscopy.     

Capsule endoscopy in non-steroidal anti-inflammatory drugs-enteropathy and miscellaneous, rare intestinal diseases

Despite significant advances over the last decade, mucosal lesions of the small bowel are poorly detected by imaging studies such as CT scan, MRI-enteroclysis and contrast-enhanced abdominal ultrasound. Capsule endoscopy （CE） has dramatically changed the diagnostic approach to intestinal diseases. Moreover, the use of CE can be extended to include other conditions. However, it is diffi cult to assess the positive influence of CE on patient outcomes in conditions involving a small number of patients, or in critically ill and diff icult to examine patients. CE has the advantage of diagnosing intestinal lesions and of directing the use of double balloon enteroscopy （DBE） in order to obtain biopsy specimens. Moreover, CE allows repeated assessment in chronic conditions, especially to detect relapse of an infectious disease.     

Diagnosis and therapeutic strategies for small bowel vascular lesions

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions;therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.     

Role of videocapsule endoscopy for gastrointestinal bleeding

Obscure gastrointestinal bleeding （OGIB） is defi ned as bleeding of an unknown origin that persists or recurs after negative initial upper and lower endoscopies. Several techniques, such as endoscopy, arteriography, scintigraphy and barium radiology are helpful for recognizing the bleeding source; nevertheless, in about 5%-10% of cases the bleeding lesion cannot be determined. The development of videocapsule endoscopy （VCE） has permitted a direct visualization of the small intestine mucosa. We will analyze those techniques in more detail. The diagnostic yield of CE for OGIB varies from 38% to 93%, being in the higher range in those cases with obscure-overt bleeding.     

Diagnostic Yield and Impact of Capsule Endoscopy on Management of Patients with Gastrointestinal Bleeding of Obscure Origin

This study assessed diagnostic yield and impact of capsule endoscopy on patient management. Seventy-five patients with obscure gastrointestinal bleeding were included. Clinical and followup information was collected by review of patient records and with personal contact with the referring physicians. All previous clinical information and interventions after capsule endoscopy and clinical outcome were noted. The indication was obscure-overt gastrointestinal bleeding in 36 patients (48%) and obscure-occult gastrointestinal bleeding in 39 patients (52%). Overall diagnostic yield was 66.7% considering relevant lesions. Followup was available in 31 patients. Capsule endoscopy changed clinical management in 61.4%. Multivariate analysis showed that patients with another potential source of bleeding and patients whose onset was hematochezia were not good candidates for capsule endoscopy. Capsule endoscopy has a high diagnostic yield and a positive influence on clinical management in a high proportion of patients with obscure gastrointestinal bleeding.     

Capsule Endoscopy Versus Push Enteroscopy for Evaluation of Obscure Gastrointestinal Bleeding with 1-Year Outcomes

Because of the low diagnostic yield of standard radiologic tests for identifying sources of obscure gastrointestinal bleeding in the small intestine, we compared wireless video capsule endoscopy with push enteroscopy and small-bowel follow-through. Patients referred to Mayo Clinic, Scottsdale, Arizona, between August and December 2001 for evaluation of obscure gastrointestinal bleeding were potential candidates. Eligible patients had previously inconclusive endoscopy, colonoscopy, small-bowel follow-through, and other radiologic studies. Participants underwent capsule endoscopy and enteroscopy (within 24 hr). The primary end point was localization of any bleeding source, with 1-year telephone follow-up. Capsule endoscopy yielded positive findings in 10 of 20 patients (11 men; mean age, 69 years), 6 of whom had negative enteroscopy and small-bowel follow-through. No patient with negative findings on capsule endoscopy had positive findings on enteroscopy and small-bowel follow-through. At follow-up, 19 patients reported fewer transfusions, gastrointestinal procedures, and hospitalizations. Capsule endoscopy identified more lesions and improved outcomes.Published as an abstract at Digestive Disease Week, San Francisco, California, May 19–22, 2002.     

Capsule endoscopy findings in patients with suspected Crohn''s disease and biochemical markers of inflammation

BACKGROUND: Because it provides a direct view of superficial lesions in the small bowel, capsule endoscopy is a promising diagnostic tool for studying patients with suspected Crohn's disease undetected by conventional modalities. AIM: To assess the role of capsule endoscopy in the diagnosis of patients with suspected Crohn's disease. PATIENTS AND METHODS: Thirty-eight patients (16 males, mean age 46.2 years) with suspected Crohn's disease but negative at conventional imaging were examined using capsule endoscopy. They were divided into 2 groups: 12 patients with ongoing symptoms (Group 1), and 26 with ongoing symptoms and biochemical markers of inflammation (Group 2). Capsule endoscopy findings were classified as diagnostic (multiple erosions/ulcerations), suspicious (相似文献   

Are repeat upper gastrointestinal endoscopy and colonoscopy necessary within six months of capsule endoscopy in patients with obscure gastrointestinal bleeding?

Background and Aim: Medicare reimbursement for capsule endoscopy for the investigation of obscure gastrointestinal bleeding in Australia requires endoscopy and colonoscopy to have been performed within 6 months. This study aims to determine the diagnostic yield of repeating these procedures when they had been non‐diagnostic more than 6 months earlier. Methods: Of 198 consecutive patients who were referred for the investigation of obscure gastrointestinal bleeding, 50 underwent repeat endoscopy and colonoscopy solely to enable reimbursement (35 females and 15 males; mean age 59.4 [range: 21–82] years). The average duration of obscure bleeding was 50.16 (range: 9–214) months. The mean number of prior endoscopies was 3 (median: 2) and 2.8 colonoscopies (median: 2). The most recent endoscopy had been performed 18.9 (median: 14; range: 7–56) months, and for colonoscopy, 19.1 (median 14; range 8‐51) months earlier. Results: A probable cause of bleeding was found at endoscopy in two patients: gastric antral vascular ectasia (1) and benign gastric ulcer (1). Colonoscopy did not reveal a source of bleeding in any patient. Capsule endoscopy was performed in 47 patients. Twenty four (51%) had a probable bleeding source identified, and another five (11%) a possible source. These included angioectasia (17 patients), mass lesion (2), non‐steroidal anti‐inflammatory drug enteropathy (2), Cameron's erosions (2), and Crohn's disease (1). Four patients undergoing repeat capsule endoscopy had a probable bleeding source detected. Conclusion: The yield of repeat endoscopy and colonoscopy immediately prior to capsule endoscopy is low when these procedures have previously been non‐diagnostic. Such an approach is also not cost‐effective.     

Diagnostic yield of dual-phase computed tomography enterography in patients with obscure gastrointestinal bleeding and a non-diagnostic capsule endoscopy

Background and Aim: In patients with obscure gastrointestinal (GI) bleeding, capsule endoscopy is widely used to determine the source of bleeding. However, there is currently no consensus on how to further evaluate patients with obscure GI bleeding with a non‐diagnostic capsule endoscopy examination. This study aims to determine the diagnostic yield of dual‐phase computed tomographic enterography (CTE) in patients with obscure GI bleeding and a non‐diagnostic capsule endoscopy. Methods: Patients with obscure GI bleeding who were referred for capsule endoscopy were prospectively enrolled. Obscure GI bleeding was defined as overt if there was obvious GI bleeding; otherwise it was defined as occult. Patients with a non‐diagnostic capsule endoscopy and no contraindications underwent a CTE. Results: Capsule endoscopy was performed in 52 patients; 26 patients (50%) had occult GI bleeding and 26 patients (50%) had overt GI bleeding. CTE was then performed in 25 of the 48 patients without a definitive source of bleeding seen on capsule endoscopy. The diagnostic yield of CTE was 0% (0/11) in patients with occult bleeding versus 50% (7/14) in patients with overt bleeding (P < 0.01). Using clinical follow up as the gold standard, for the 25 patients with a non‐diagnostic capsule, CTE had a sensitivity of 33% (95% confidence interval 0.15, 0.56) and a specificity of 75% (95% confidence interval 0.22, 0.99). Conclusions: In patients with a non‐diagnostic capsule endoscopy examination, CTE is useful for detecting a source of GI bleeding in patients with overt, but not occult, obscure GI bleeding.     

胶囊内镜在小肠疾病诊断中的作用

目的:小肠疾病很难诊断,现有的诊断技术又不尽如人意,而胶囊内镜能发现整个小肠内的微小病变。为此,我们对胶囊内镜在小肠疾病诊断中的价值进行评估。方法:自2002年5月至2003年9月,我们对经结肠镜、胃镜、X线钡餐造影、小肠钡灌造影、血管造影或核素扫描等检查未发现异常的79例疑患小肠疾病、尤其是不明原因消化道出血的患者,进行胶囊内镜检查,其中不明原因的消化道出血患者56例。结果:75例完成最终研究。75例患者中经胶囊内镜检查共发现异常63例,检出率为84％;其中能明确解释临床病因者50例,诊断率为66.6％,包括消化道血管病变21例、小肠炎症性肠病16例、小肠息肉5例、小肠恶性间质肿瘤2例、小肠类癌1例(该患者同时伴升结肠脂肪瘤)、淋巴瘤1例、粘膜下肿瘤3例及憩室1例。所获取的图像质量良好。结论:胶囊内镜对小肠疾病尤其是不明原因消化道出血具有良好的诊断价值。     

Wireless capsule endoscopy for obscure small-bowel disorders: final results of the first pediatric controlled trial.

BACKGROUND AND AIMS: Obscure small-bowel disorders are jejunal and ileal lesions undiagnosed by traditional imaging techniques (endoscopic, radiologic). We evaluated the diagnostic usefulness and safety of capsule endoscopy for obscure small-bowel disorders in children and adolescents. METHODS: Comparative, prospective, self-controlled trials in patients (age, 10-18 y) suspected to have either small-bowel Crohn's disease, polyps, or obscure gastrointestinal (GI) bleeding. Capsule results were compared with the diagnostic imaging studies normally used in this age group. RESULTS: Among 20 patients suspected of Crohn's disease, multiple lesions consistent with this diagnosis were observed by capsule endoscopy in 50%. Small-bowel Crohn's disease was ruled out in 8 patients. Eosinophilic enteropathy was found in 2 others. For polyp detection (n = 6), capsule endoscopy yielded 100% concordance with the control studies when analyzed per patient. However, capsule endoscopy revealed a greater number (50%) of polyps. Among patients with obscure bleeding (n = 4), the capsule examination confirmed a diagnosis of vascular malformations in 3. Capsule endoscopy more accurately identified the precise source of bleeding compared with angiography. All 30 capsule studies were well tolerated, although 1 capsule was retained owing to an inflammatory stenosis. The capsule eventually was expelled after corticosteroid therapy. CONCLUSIONS: Capsule endoscopy correctly diagnosed or excluded a bleeding source, small-bowel polyps, or Crohn's disease of the small bowel in 29 of 30 patients. Capsule endoscopy permits an accurate, noninvasive approach for diagnosing obscure small bowel lesions in children over the age of 10.     

The role of capsule endoscopy in obscure gastrointestinal bleeding

Background and study aimObscure gastrointestinal bleeding is mostly recurrent and originates in the small bowel, which can be only partially examined by conventional endoscopy. Capsule endoscopy has revolutionized the evaluation of obscure gastrointestinal bleeding (OGIB). The diagnostic yield of capsule endoscopy in OGIB was a main concern of many studies. The aim of this study is to assess the diagnostic yield of capsule endoscopy in cases of OGIB. Capsule-related complications and degree of inter-observer variation will be recorded as well.Patients and methods54 consecutive patients suffering from OGIB, whether occult or overt, were subjected to capsule examination and data analysis.ResultsThe majority (74.1%) presented with obscure overt bleeding. Examination was complete in 68.4%. The commonest lesions were angiodysplasias (17.5%). Examinations were negative for lesions in 35.1% and hampered by limitations in 19.3%. The capsule diagnostic yield was 56.1%, while capsule retention occurred in 3.5%. The inter-observer agreement for the cause of bleeding was 91.2%.ConclusionsCapsule endoscopy proved helpful in solving the mystery of OGIB. It succeeded in diagnosing the cause of bleeding and directing further management with good compliance, high proportion of inter-observer agreement and low incidence of complications.     

Wireless capsule endoscopy for diagnosis of small intestinal lesions

Background: Capsule endoscopy represents a new and highly innovative method of visualizing the small intestine. The aim of the present study was to evaluate the practicality, usefulness and diagnostic yield of capsule endoscopy in a group of patients with suspected small intestinal disease. Methods: Eleven patients underwent capsule endoscopy using the M2A Capsule Endoscope? (Given Imaging, Yogneam, Israel). The indications for the procedure were: obscure gastrointestinal (GI) bleeding in seven patients, evaluation of Crohn's disease in three patients and unexplained abdominal pain and weight loss in one patient. Results: Abnormalities were detected in six of 11 patients overall. Detection of abnormalities was highest among patients with obscure GI bleeding where active bleeding and/or the source of bleeding was identified in five of the seven (71.4%) patients. One of the three patients with Crohn's disease had an ileal ulcer detected, while the remaining patient with unexplained weight loss and pain had a normal examination. Conclusion: We have found in our preliminary experience that capsule endoscopy is a useful and practical procedure to perform especially for evaluation of obscure GI bleeding.     

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.