Capsule endoscopy changes patient management in routine clinical practice

Comparison of patient tolerance and acceptability of magnet-controlled capsule endoscopy and flexible endoscopy in the investigation of dyspepsia

Background and study aims  Oropharyngeal intubation during Esophagogastroduodenoscopy (EGD) is uncomfortable, associated with aerosol generation and transmission of airborne microbes. Less-invasive alternatives may be better tolerated. In this study, patient tolerance and acceptability of EGD and transnasal endoscopy (TNE) have been compared with magnet-controlled capsule endoscopy (MACE). Patients and methods  A comparison of MACE with EGD and TNE in the investigation of dyspepsia was performed. Factors affecting patient tolerance and acceptability were examined using the Endoscopy Concerns Scale (ECS) and Universal Patient Centeredness Questionnaire (UPC-Q). Results  Patients were significantly more distressed (scoring least to most distress: 1-10) by gagging (6 vs 1), choking (5 vs 1), bloating (2 vs 1), instrumentation (4 vs 1), discomfort during (5 vs 1) and after (2 vs 1) EGD compared to MACE (all P  < 0.0001). Patients were more distressed by instrumentation (5 vs 1) and discomfort during (5 vs 1) TNE compared to MACE ( P  = 0.001). Patients were more accepting of MACE than EGD and TNE with a UPC-Q score (scoring least to most acceptable: 0-100) lower for EGD (50 vs 98, P  < 0.0001) and TNE (75 vs 88, P  = 0.007) than MACE, and a post-procedure ECS score (scoring most to least acceptable: 10-100) higher for EGD (34 vs 11, P  < 0.0001) and TNE (25 vs 10.5, P  = 0.001) than MACE. MACE would be preferred by 83 % and 64 % of patients even if EGD or TNE respectively was subsequently recommended to obtain biopsies in half of examinations. Conclusions  Gagging and choking during instrumentation, the main causes of patient distress during EGD, occurred less during TNE but tolerance, acceptability and patient experience favored MACE.

Magnetically assisted capsule endoscopy in suspected acute upper GI bleeding versus esophagogastroduodenoscopy in detecting focal lesions

BACKGROUND AND AIMS

Acute upper GI bleeding is common and requires investigation with EGD, but endotherapy is not always necessary. Magnetically assisted capsule endoscopy (MACE) uses a capsule steerable by an external magnet and allows examination of the upper GI tract and small bowel, but its role in acute upper GI bleeding has not been assessed.

METHODS

We conducted a prospective cohort study comparing the diagnostic yield of MACE and EGD in patients with suspected acute upper GI bleeding. Patient tolerance, mucosal visibility by MACE, and frequency of small-bowel bleeding were assessed. Whether or not MACE could safely predict discharge of patients was also determined.

RESULTS

Thirty-three patients were included for analysis (median age, 60 years; 75.8% male). MACE detected more focal lesions (peptic, vascular, and fresh/altered blood without a clear source) than EGD (40 versus 25, respectively, P = .02) but statistical significance was not reached for significant lesions (considered to be the bleeding source; 14 vs 13, respectively, P = 1). Capsule endoscopy identified an additional cause for bleeding in the small bowel in 18%. Visualization by MACE was excellent in most areas; views of the esophagus, gastroesophageal junction, fundus, and duodenal bulb were suboptimal. MACE was better tolerated than unsedated EGD and correctly identified patients who were safe for discharge.

CONCLUSIONS

MACE had higher diagnostic yield for focal lesions and was better tolerated than EGD. It also correctly predicted safe discharge for patients with acute upper GI bleeding. (Clinical trials registration number: NCT02690376.).

No significant difference in clinically relevant findings between Pillcam® SB3 and Pillcam® SB2 capsules in a United States veteran population

BACKGROUND

Capsule endoscopy (CE) allows for a non-invasive small bowel evaluation for a wide range of gastrointestinal (GI) symptoms and diseases. Capsule technology has been rapidly advancing over recent years, often improving image frequency and quality. The Pillcam^® SB3 (SB3) capsule is one such technology that offers an adaptive frame rate advantage over the previous versions of the capsule the Pillcam^® SB2 (SB2). Some have proposed that this improvement in capsule technology may lead to increased diagnostic yields; however, real world clinical data is currently lacking.

AIM

To evaluate the clinically relevant findings of SB3 and SB2 capsules in a population of United States veterans.

METHODS

A retrospective analysis of 260 consecutive CE studies was performed including 130 SB3 and 130 SB2 capsule studies. Recorded variables included: age, gender, type of capsule, body mass index, exam completion, inpatient status, opioid use, diabetes, quality of preparation, gastric transit time, small bowel transit time, indication, finding, and if the exam resulted in a change in clinical management. The primary outcome measured was the detection of clinically relevant findings between SB3 and SB2 capsules.

RESULTS

Mean age of the study population was 67.1 ± 10.4 years and 94.2% of patients were male. Of these 28.1% were on opioid users. The most common indications for capsule procedure were occult GI bleeding (74.6%) and overt GI bleeding (14.6%). Rates of incomplete exam were similar between SB3 and SB2 groups (16.9% vs 9.2%, P = 0.066). The overall rate of clinically relevant finding was 48.9% in our study. No significant difference was observed in SB3 vs SB2 capsules for clinically relevant findings (46.2% vs 51.5%, P = 0.385) or change in clinical management (40.8% vs 50.0%, P = 0.135).

CONCLUSION

Our study found no significant difference in clinically relevant findings between SB3 and SB2 capsules.

A comparison study between Magniview and high definition white light endoscopy in detecting villous atrophy and coeliac disease: A single centre pilot study

BACKGROUND AND AIMS

Coeliac disease may be missed at gastroscopy. We aimed to assess the sensitivity of Pentax optical zoom technology endoscopes in detecting duodenal villous atrophy and the ease of image interpretation by non-coeliac specialists.

METHOD

All patients attending for a gastroscopy were assessed for endoscopic villous atrophy in part one and two of the duodenum with high definition white light endoscopy and magnification endoscopy. Endoscopic findings of the duodenum were compared to histology as the reference standard. A short training video of varying degrees of villous atrophy seen by magnification endoscopy was used to train individuals. They were then assessed for the ability to differentiate between normal duodenum and villous atrophy.

RESULTS

Two hundred and fifty patients were prospectively recruited (145 females, 58%; age range 16-84, median age 50.5). Ninety-six patients had villous atrophy on histology (38.4%) 154 were controls. Magnification endoscopy had a higher sensitivity in detecting villous atrophy compared to high definition white light endoscopy (86.4% versus 78.4%, p = .0005). 9/10 individuals undertaking magnification endoscopy training correctly identified all cases of villous atrophy.

CONCLUSION

Magnification endoscopy has superior diagnostic sensitivity in detecting villous atrophy compared to high definition white light endoscopy and the potential to be easily adopted by all endoscopists.

Small-Bowel Capsule Endoscopy in Clinical Practice: Has Anything Changed Over 13 Years?

BACKGROUND

In Lombardia, one of the 20 Italian administrative Regions, small-bowel capsule endoscopy (SBCE) was introduced in 2001. In January 2011, the Regional Health Authorities established a reimbursement for outpatient SBCE.

AIM

To prospectively record data on SBCE between 2011-2013 and compare them to similar data retrospectively collected from the same geographical area (covering the period 2001-2008) and published in 2008.

METHODS

Consecutive SBCEs performed between January 2011 and December 2013 in Lombardia were prospectively collected.

RESULTS

In 3 years, 3142 SBCEs were collected; the diagnostic yield (DY) and the overall complication rate were 48.4 and 0.9%, respectively. The main indication was suspected small-bowel bleeding (76.6% of patients); complete small-bowel inspection was achieved in 2796 (89.0%) patients. SBCE was performed as an outpatient procedure in 1945 patients (61.9%). A significant increase in the rate of patients undergoing SBCE for suspected small-bowel bleeding was observed from 2001-2008 to 2011-2013 (67.3 vs. 76.1%; p < 0.001). There was an increase in the number of complete small-bowel examinations (81.2 vs. 89.0%; p < 0.001) and of outpatient SBCEs (6.7 vs. 61.9%; p < 0.001). Conversely, both the retention rate (2.1 vs. 0.8%; p < 0.001) and the rate of patients undergoing SBCE for Crohn's disease (11.5 vs. 5.5%; p < 0.001) decreased significantly. The overall DY remained stable (50.6 vs. 48.4%; p = 0.089).

CONCLUSION

Our study shows that, over 13 years, the SBCE safety profile and completion rate significantly improved over time; a change in the spectrum of clinical indications was also observed.

Does magnetically assisted capsule endoscopy improve small bowel capsule endoscopy completion rate? A randomised controlled trial

BACKGROUND AND STUDY AIMS

Delayed gastric emptying is a significant factor in incomplete small bowel capsule examinations. Gastric transit could be hastened by external magnetic control of the capsule. We studied the feasibility of this approach to improve capsule endoscopy completion rates.

PATIENTS AND METHODS

Prospective, single-center, randomized controlled trial involving 122 patients attending for small bowel capsule endoscopy using MiroCam Navi. Patients were randomized to either the control group (mobilisation for 30 minutes after capsule ingestion, followed by intramuscular metoclopramide 10 mg if the capsule failed to enter the small bowel) or the intervention group (1000 mL of water prior to capsule ingestion, followed by positional change and magnetic steering). Outcome measures were capsule endoscopy completion rate, gastric clarity and distention, relationship of body habitus to capsule endoscopy completion rate (CECR), and patient comfort scores.

RESULTS

122 patients were recruited (61 each to the control and intervention groups: mean age 49 years [range 21 - 85], 61 females). There was no significant difference in CECR between the two groups (P = 0.39). Time to first pyloric image was significantly shorter in the intervention group (P = 0.03) but there was no difference in gastric transit times (P = 0.12), suggesting that magnetic control hastens capsular transit to the gastric antrum but does not influence duodenal passage. Gastric clarity and distention were significantly better in the intervention group (P < 0.0001 and P < 0.0001 respectively).

CONCLUSIONS

Magnetic steering of a small bowel capsule is unable to overcome pyloric contractions to enhance gastric emptying and improve capsule endoscope completion rate. Excellent mucosal visualisation within the gastric cavity suggests this technique could be harnessed for capsule examination of the stomach.

Overview of technical solutions and assessment of clinical usefulness of capsule endoscopy

The paper presents an overview of endoscopic capsules with particular emphasis on technical aspects. It indicates common problems in capsule endoscopy such as: (1) limited wireless communication (2) the use of capsule endoscopy in the case of partial patency of the gastrointestinal tract, (3) limited imaging area, (4) external capsule control limitations. It also presents the prospects of capsule endoscopy, the most recent technical solutions for biopsy and the mobility of the capsule in the gastrointestinal tract. The paper shows the possibilities of increasing clinical usefulness of capsule endoscopy resulting from technological limitations. Attention has also been paid to the current role of capsule endoscopy in screening tests and the limitations of its effectiveness. The paper includes the author's recommendations concerning the direction of further research and the possibility of enhancing the scope of capsule endoscopy.

Overview of technical solutions and assessment of clinical usefulness of capsule endoscopy

The paper presents an overview of endoscopic capsules with particular emphasis on technical aspects. It indicates common problems in capsule endoscopy such as: (1) limited wireless communication (2) the use of capsule endoscopy in the case of partial patency of the gastrointestinal tract, (3) limited imaging area, (4) external capsule control limitations. It also presents the prospects of capsule endoscopy, the most recent technical solutions for biopsy and the mobility of the capsule in the gastrointestinal tract. The paper shows the possibilities of increasing clinical usefulness of capsule endoscopy resulting from technological limitations. Attention has also been paid to the current role of capsule endoscopy in screening tests and the limitations of its effectiveness. The paper includes the author's recommendations concerning the direction of further research and the possibility of enhancing the scope of capsule endoscopy.

Gastrointestinal bleeding

• On the basis of strong research evidence, children with severe upper gastrointestinal tract bleeding should be treated with intravenous proton pump inhibitors. • On the basis of some research evidence and consensus, children with severe gastrointestinal bleeding should be evaluated by endoscopy. • On the basis of some research evidence and consensus, children in whom endoscopy has not been able to confirm a bleeding source should be considered for capsule endoscopy.

Gastrointestinal bleeding

• On the basis of strong research evidence, children with severe upper gastrointestinal tract bleeding should be treated with intravenous proton pump inhibitors. • On the basis of some research evidence and consensus, children with severe gastrointestinal bleeding should be evaluated by endoscopy. • On the basis of some research evidence and consensus, children in whom endoscopy has not been able to confirm a bleeding source should be considered for capsule endoscopy.

Provision of service and training for small bowel endoscopy in the UK

OBJECTIVE

To determine the location and use of small bowel endoscopy services in the UK and to analyse training uptake to assess future demand and shape discussions about training and service delivery.

DESIGN

Surveys of British Society of Gastroenterology (BSG) members by web-based and personal contact were conducted to ascertain capsule endoscopy practice and numbers of procedures performed. This was compared with expected numbers of procedures calculated using BSG guidelines, hospital episode statistics and published data of capsule endoscopy in routine practice. Analysis of data from two national training courses provided information about training.

RESULTS

45% of UK gastroenterology services offered in-house capsule endoscopy. 91.3% of survey responders referred patients for capsule endoscopy; 67.7% felt that local availability would increase referrals. Suspected small bowel bleeding and Crohn's disease were considered appropriate indications by the majority. Demand is increasing in spite of restricted use in 21.6% of centres. Only two regions performed more than the minimum estimate of need of 45 procedures per 250 000 population. Eight centres perform regular device-assisted enteroscopy; 14 services are in development. 74% of trainees were interested in training and of those training in image interpretation, 67% are doctors and 28% are nurses.

CONCLUSIONS

Capsule endoscopy is used by the majority of UK gastroenterologists but appears to be underused. Current demand for device-assisted enteroscopy seems likely to be matched if new services become established. Future demand is likely to increase, however, suggesting the need to formalise training and accreditation for both doctors and nurses.

Capsule endoscopy: 10 years on and in the frontline

Capsule endoscopy is a safe, simple, remote method of visualising the gastrointestinal tract without resorting to conventional endoscopic intubation or radiation exposure. In addition, the ability to visualise the small bowel mucosa directly means that it is considerably more sensitive than existing small bowel imaging modalities in detecting subtle abnormalities. It is a firstline investigative modality for suspected small bowel bleeding and is being increasingly used for detecting evidence of other small bowel diseases. In Crohn's disease, it can confirm evidence of activity without recourse to repeated endoscopic intubation or radiation but does not replace MRI and CT which are better suited to defining stricturing disease and transmural complications. The production of different capsule endoscopes to examine the oesophagus, small bowel and colon now means that almost all of the gut can be examined using this technology.

Impact of capsule endoscopy findings in the management of Crohn's Disease

BACKGROUND

Capsule endoscopy (CE) has proven efficacy in detecting mucosal lesions of the upper gastrointestinal tract and it has been widely evaluated for assessing small-bowel lesions in patients with suspected or established Crohn's disease (CD).

AIMS

To evaluate the impact of CE on the management of patients with established CD.

METHODS

All patients with known CD that underwent CE were identified from IBD and endoscopy databases. Baseline characteristics of the study population, CE findings, changes in therapy, and patient outcome were recorded. Patients were followed for 18 months after CE.

RESULTS

CE was performed in 14 CD patients for iron deficiency anemia (n = 5) or abdominal pain of unknown origin (n = 3), or re-evaluation of disease location (n = 6). The overall diagnostic yield was 85.7%. As a result of the CE findings, CD therapy was changed in 64% of cases. Clinical outcome changed in three out of five patients with iron deficiency anemia and in two out of three patients with abdominal pain.

CONCLUSIONS

CE has a high diagnostic yield even in patients with previously known CD, and its findings may influence disease management and clinical outcome.

Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review

BACKGROUND

Capsule endoscopy (CE) has been widely used in clinical practice.

OBJECTIVE

To provide systematically pooled results on the indications and detection, completion, and retention rates of small-bowel CE.

DESIGN

A systematic review.

MAIN OUTCOME MEASUREMENTS

We searched the PubMed database (2000-2008) for original articles relevant to small-bowel CE for the evaluation of patients with small-bowel signs and symptoms. Data on the total number of capsule procedures, the distribution of different indications for the procedures, the percentages of procedures with positive detection (detection rate), complete examination (completion rate), or capsule retention (retention rate) were extracted and/or calculated, respectively. In addition, the detection, completion, and retention rates were also extracted and/or calculated in relation to indications such as obscure GI bleeding (OGIB), definite or suspected Crohn's disease (CD), and neoplastic lesions.

RESULTS

A total of 227 English-language original articles involving 22,840 procedures were included. OGIB was the most common indication (66.0%), followed by the indication of only clinical symptoms reported (10.6%), and definite or suspected CD (10.4%). The pooled detection rates were 59.4%; 60.5%, 55.3%, and 55.9%, respectively, for overall, OGIB, CD, and neoplastic lesions. Angiodysplasia was the most common reason (50.0%) for OGIB. The pooled completion rate was 83.5%, with the rates being 83.6%, 85.4%, and 84.2%, respectively, for the 3 indications. The pooled retention rates were 1.4%, 1.2%, 2.6%, and 2.1%, respectively, for overall and the 3 indications.

LIMITATIONS

Inclusion and exclusion criteria were loosely defined.

CONCLUSIONS

The pooled detection, completion, and retention rates are acceptable for total procedures. OGIB is the most common indication for small-bowel CE, with a high detection rate and low retention rate. In addition, angiodysplasia is the most common finding in patients with OGIB. A relatively high retention rate is associated with definite or suspected CD and neoplasms.

Enteroscopy in the diagnosis and management of obscure gastrointestinal bleeding

Capsule endoscopy and balloon-assisted enteroscopy, have revolutionized our approach to the diagnosis and management of patients with obscure gastrointestinal bleeding, largely replacing intraoperative enteroscopy and conventional barium studies. Despite its limitations, capsule endoscopy may well be the most reasonable initial diagnostic strategy to evaluate most patients with obscure gastrointestinal bleeding, leaving balloon-assisted enteroscopy in reserve as a complementary tool. This article reviews the data on enteroscopy, with particular emphasis on the use of capsule endoscopy and balloon-assisted enteroscopy for the diagnosis and management of patients with obscure gastrointestinal bleeding.

Capsule endoscopy's impact on clinical management and outcomes: a single-center experience with 145 patients

BACKGROUND

Capsule endoscopy (CE) is a new technology that has been shown to have superior diagnostic yield compared with other methods of evaluating the small bowel. However, there have not been many studies supporting capsule endoscopy's impact on clinical outcomes. This study is a chart review evaluating the diagnostic yield and the impact of CE on management and clinical outcomes.

METHODS

Retrospective chart review was performed on 145 patients who had undergone capsule endoscopy. Demographic characteristics, indication, prior diagnostic tests, capsule findings, interventions, and clinical outcomes up to 8 months following CE were evaluated. Indications included five main categories that were overt gastrointestinal (GI) bleed, occult GI bleed, abdominal pain, Crohn's disease, and iron deficiency anemia. Findings on capsule endoscopy were classified into angiodysplasias, ulcers, gastritis and/or duodenitis, ulcers suggestive of Crohn's and normal findings. Interventions performed based on capsule findings were recorded, which included the discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDS), further diagnostic or therapeutic studies, increase in medications, and surgery. Positive outcomes including stabilization or improvement of hemoglobin, decreased need for transfusions, improved symptoms of pain, and a decrease in medications based on interventions were assessed.

RESULTS

There were 145 patients who underwent CE. The indications for CE were overt GI bleed (38%), occult GI bleed (22%), abdominal pain (20%), Crohn's (12%), iron deficiency anemia (2.7%), and miscellaneous (4%). Eighty percent achieved completion and 6 patients had complications of capsule retention with 4 requiring surgery. The overall diagnostic yield was 69% and included findings of angiodysplasias (24%), intestinal ulcers (13%) gastritis or duodenitis (13.8%), ulcers suggestive of Crohn's disease (8.9%), and mass or polyp (3.4%). Based on capsule findings, 35.8% of patients had an intervention. Of the patients who received intervention, 71.7% had a positive clinical outcome (P= 0.032).

CONCLUSIONS

The high diagnostic yield of CE influences clinical management leading to improved outcomes. However, the utility of CE may be greater in patients who are referred for certain indications or have specific findings. Additional studies are needed to clarify the role of capsule endoscopy in the evaluation of various indications as well as identify factors associated with positive outcomes.

Correlation between predicted and actual consequences of capsule endoscopy on patient management

BACKGROUND

Capsule endoscopy (CE) is a relatively new diagnostic modality in the evaluation of patients with suspected small bowel pathology. It is unclear to what extent physicians are able to predict the clinical consequences of CE on patient management.

METHODS

In this prospective study, 180 consecutive CE examinations were analysed. Prior to CE, referring physicians were asked to indicate the consequences of CE according to potential different CE outcomes. The influence of CE on patient management was determined with at least 1 year follow-up. Management consequences were defined as major (surgical or endoscopic intervention, or medical therapy) or minor (nonspecific therapy, including iron supplementation, or no further diagnostic tests).

RESULTS

CE led to major management consequences in 32% of cases. Of patients with obscure gastrointestinal bleeding and normal CE findings, 91% were independent of blood transfusions and experienced no further bleeding episodes during a mean follow-up of 33 months. In 78% of 118 cases that were evaluated, the actual consequences of CE matched the consequences predicted by the referring physicians.

CONCLUSION

CE had a major impact on patient management in about one third of investigations. In the majority of cases, physicians adequately predicted the clinical consequences of CE.

CT features of jejunal pathology

The imaging of duodenal and ileal diseases is well documented in radiological literature but the jejunum has been relatively neglected. The aim of this review is to outline the current methods of investigation of the jejunum, and provide a comprehensive review of common pathologies affecting the jejunum, with particular emphasis on investigation by computed tomography.