Study comparing oesophageal capsule endoscopy versus EGD in the detection of varices

Endoscope Capsules: The Present Situation and Future Outlooks

This paper presents new perspectives on photonic technologies for capsule endoscopy. It first presents a review of conventional endoscopy (upper endoscopy and colonoscopy), followed by capsule endoscopy (CE), as well as their techniques, advantages, and drawbacks. The technologies for CEs presented in this paper include integration with the existing endoscopic systems that are commercially available. Such technologies include narrow-band imaging (NBI), photodynamic therapy (PDT), confocal laser endomicroscopy (CLE), optical coherence tomography (OCT), and spectroscopy in order to improve the performance of the gastrointestinal (GI) tract examination. In the context of NBI, two optical filters were designed and fabricated for integration into endoscopic capsules, allowing for the visualization of light centered at the 415 nm and 540 nm wavelengths. These optical filters are based on the principle of Fabry-Perot and were made of thin films of titanium dioxide (TiO2) and silicon dioxide (SiO2). Moreover, strategies and solutions for the adaptation of ECs for PDT are also discussed.

Esophageal Capsule Endoscopy in Children and Young Adults With Portal Hypertension

OBJECTIVES

Variceal hemorrhage (VH) is a serious complication of portal hypertension (PH). We evaluated the feasibility, safety, and clinical impact of esophageal capsule endoscopy (ECE) in pediatric and young adult patients with known or suspected PH.

METHODS

Children and young adults with PH at Boston Children's Hospital (2005-2017) were offered ECE for variceal screening or surveillance. Patient histories, ECE findings, and clinical outcomes were reviewed retrospectively.

RESULTS

One hundred and forty-nine ECE studies were performed in 98 patients (57.1% male patients) using 3 ECE devices for variceal screening (66.5%) or surveillance (33.5%). Three readers interpreted the studies (88.3%, 10.3%, and 1.4%, respectively). Median age was 16 years (IQR 13.7-18.5). One hundred and three ECE studies involved patients <18 years (69.1%). Fifteen patients (29 ECE studies) had a gastrointestinal (GI) bleeding (GIB) history, 5 in the preceding 12 months.Sixty-two ECE studies (44.9%) detected varices: 59 esophageal (40 small, 19 medium/large), 17 gastric, 6 duodenal. Other findings included: portal gastropathy (25, 18.1%), esophagitis (20, 14.5%), ulcers (5, 3.6%), erosions (31, 22.5%), heterotopic tissue (13, 9.4%), blood flecks (23, 16.7%), and mucosal scars (17, 12.3%). There were 2 transient capsule retentions and no major adverse events.ECE led to follow-up EGD in 11 (7 variceal banding) and medication initiation in 12 (4 proton-pump inhibitor, 7 nonselective beta blocker, 2 other) cases. Four patients had GIB within 12 months of ECE.

CONCLUSION

ECE is a feasible alternative to EGD for screening and surveillance of esophageal varices in children and young adults.

Current and Future Use of Esophageal Capsule Endoscopy

Capsule endoscopy can be a diagnostic option for patients with esophageal diseases who cannot tolerate esophagogastroduodenoscopy.Functional modifications of the capsule allow for thorough examination of the esophagus. Esophageal capsule endoscopy has so farfailed to show sufficient performance to justify the replacement of traditional endoscopy for the diagnosis of esophageal diseasesbecause the esophagus has a short transit time and common pathologies appear near the esophagogastric junction. However,technological improvements are being introduced to overcome the limitations of capsule endoscopy, which is expected to become agood alternative to conventional endoscopy.

Ultrathin disposable gastroscope for screening and surveillance of gastroesophageal varices in patients with liver cirrhosis: a prospective comparative study

BACKGROUND AND AIMS

This study aims to evaluate the role of unsedated, ultrathin disposable gastroscopy (TDG) against conventional gastroscopy (CG) in the screening and surveillance of gastroesophageal varices (GEVs) in patients with liver cirrhosis.

METHOD

Forty-eight patients (56.4 ± 1.3 years; 38 male, 10 female) with liver cirrhosis referred for screening (n = 12) or surveillance (n = 36) of GEVs were prospectively enrolled. Unsedated gastroscopy was initially performed with TDG, followed by CG with conscious sedation. The 2 gastroscopies were performed by different endoscopists blinded to the results of the previous examination. Video recordings of both gastroscopies were validated by an independent investigator in a random, blinded fashion. Endpoints were accuracy and interobserver agreement of detecting GEVs, safety, and potential cost saving.

RESULTS

CG identified GEVs in 26 (54%) patients, 10 of whom (21%) had high-risk esophageal varices (HREV). Compared with CG, TDG had an accuracy of 92% for the detection of all GEVs, which increased to 100% for high-risk GEVs. The interobserver agreement for detecting all GEVs on TDG was 88% (κ = 0.74). This increased to 94% (κ = 0.82) for high-risk GEVs. There were no serious adverse events.

CONCLUSIONS

Unsedated TDG is safe and has high diagnostic accuracy and interobserver reliability for the detection of GEVs. The use of clinic-based TDG would allow immediate determination of a follow-up plan, making it attractive for variceal screening and surveillance programs. (Clinical trial (ANZCTR) registration number: ACTRN12616001103459.).

Use of Wireless Capsule Endoscopy for the Diagnosis and Grading of Esophageal Varices in Patients With Portal Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Esophageal variceal bleeding is a severe complication of portal hypertension with significant morbidity and mortality. Although traditional screening and grading of esophageal varices has been performed by endogastroduodenoscopy (EGD), wireless video capsule endoscopy provides a minimally invasive alternative that may improve screening and surveillance compliance.

AIM OF THE STUDY

The aim of the study was to perform a systematic review and structured meta-analysis of all eligible studies to evaluate the efficacy of wireless capsule endoscopy for screening and diagnosis of esophageal varices among patients with portal hypertension.

METHODS

Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were performed through December 2015. Bivariate and hierarchical models were used to compute the pooled sensitivity and specificity, and to plot the summary receiver operating characteristics curve with summary point and corresponding 95% confidence region. Bias of included studies was assessed using the quality assessment of diagnostic accuracy studies-2.

RESULTS

Seventeen studies from 2005 to 2015 were included in this meta-analysis (n=1328). The diagnostic accuracy of wireless capsule endoscopy in the diagnosis of esophageal varices was 90% [95% confidence interval (CI), 0.88-0.93]. The diagnostic pooled sensitivity and specificity were 83% (95% CI, 0.76-0.89) and 85% (95% CI, 0.75-0.91), respectively. The diagnostic accuracy of wireless capsule endoscopy for the grading of medium to large varices was 92% (95% CI, 0.90-0.94). The pooled sensitivity and specificity were 72% (95% CI, 0.54-0.85) and 91% (95% CI, 0.86-0.94), respectively, for the grading of medium to large varices. The use of capsule demonstrated only mild adverse events. A sensitivity analysis limited to only high quality studies revealed similar results.

DISCUSSION

Wireless esophageal capsule endoscopy is well tolerated and safe in patients with liver cirrhosis and suspicion of portal hypertension. The sensitivity of capsule endoscopy is not currently sufficient to replace EGD as a first exploration in these patients, but given its high accuracy, it may have a role in cases of refusal or contraindication to EGD.

Third-Generation Capsule Endoscopy Outperforms Second-Generation Based on the Detectability of Esophageal Varices

Background and Aim. The third-generation capsule endoscopy (SB3) was shown to have better image resolution than that of SB2. The aim of this study was to compare SB2 and SB3 regarding detectability of esophageal varices (EVs). Methods. Seventy-six consecutive liver cirrhosis patients (42 men; mean age: 67 years) received SB3, and 99 (58 men; mean age, 67 years old) received SB2. All patients underwent esophagogastroduodenoscopy within 1 month prior to capsule endoscopy as gold standard for diagnosis. The diagnosis using SB3 and SB2 for EVs was evaluated regarding form (F0–F3), location (Ls, Lm, and Li), and the red color (RC) sign of EVs. Results. SB2 and SB3 did not significantly differ on overall diagnostic rates for EV. Sensitivity, specificity, positive predictive value, and negative predictive value of SB2/SB3 for EV diagnosis were, respectively, 65%/81%, 100%/100%, 100%/100%, and 70%/62%. However, the diagnostic rates for EV form F1 were 81% using SB3 and 52% using SB2 (P = 0.009). Further, the diagnostic rates for Ls/Lm varices were 79% using SB3 and 81% using SB2, and, for Li, varices were 84% using SB3 and 52% using SB2 (P = 0.02). Conclusion. SB3 significantly improved the detectability of EVs compared with SB2.

Esophageal capsule endoscopy is not the optimal technique to determine the need for primary prophylaxis in patients with cirrhosis

INTRODUCTION

Capsule endoscopy has been suggested as a potential alternative to endoscopy for detection of esophagogastric varices and severe portal hypertensive gastropathy (PHG). The aim of the study was to determine whether PillCam esophageal capsule endoscopy could replace endoscopy for screening purposes.

MATERIAL AND METHODS

Sixty-two patients with cirrhosis with no previous variceal bleeding had PillCam capsule endoscopy and video endoscopy performed on the same day. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of capsule endoscopy were compared to endoscopy for the presence and severity of esophageal and gastric varices, PHG and the need for primary prophylaxis. Patients' preference was assessed by a questionnaire.

RESULTS

Four (6%) patients were unable to swallow the capsule. Sensitivity, specificity, PPV and NPV of capsule endoscopy for detecting any esophageal varices (92%, 50%, 92%, 50%), large varices (55%, 91%, 75%, 80%), variceal red signs (58%, 87%, 69%, 80%), PHG (95%, 50%, 95%, 50%), and the need for primary prophylaxis (91%, 57%, 78%, 80%) were not optimal, with only moderate agreement (κ) between capsule and upper GI endoscopy. Had only a capsule endoscopy been performed, 12 (21.4%) patients would have received inappropriate treatment. Capsule endoscopy also failed to detect (0/13) gastric varices. The majority of patients ranked capsule endoscopy as more convenient (69%) and their preferred (61%) method.

CONCLUSIONS

Despite the preference expressed by patients for capsule endoscopy, we believe that upper GI endoscopy should remain the preferred screening method for primary prophylaxis.

Multidetector computed tomography versus platelet/spleen diameter ratio as methods for the detection of gastroesophageal varices

BACKGROUND

All patients with liver cirrhosis should undergo screening endoscopy, but there are limitations and this approach places a heavy burden upon endoscopy units. The aim of this study was to compare multidetector computed tomography (MDCT) and the platelet/spleen diameter ratio as non-invasive methods for the detection of gastroesophageal varices.

METHODS

The study included 38 cirrhotics who underwent upper gastrointestinal (GI) endoscopy and MDCT within one month. Two radiologists reviewed the scans, in order to determine the presence and the size of varices. Blood tests and measurement of the spleen maximum diameter were also carried out and the platelet/spleen diameter ratio was calculated. Endoscopy was considered the gold standard and the results of the two methods were compared to it.

RESULTS

Varices were detected by upper GI endoscopy in 24 of 38 patients. The mean sensitivity and specificity of MDCT for the two observers was 86.1% and 57.1% respectively. In patients with large varices (>5 mm), the sensitivity was 100% (4/4). Using 909 as a cut-off value of the platelet/spleen diameter ratio this method yielded a sensitivity of 56.5% and a specificity of 35.7%. The difference in sensitivity and specificity between the two methods was statistically significant P<0.05.

CONCLUSION

MDCT was accurate for the detection of gastroesophageal varices, especially those with clinically significant size (>5 mm), and superior to platelet/spleen diameter ratio. MDCT could replace, in selected patients, upper GI endoscopy as a method for detecting gastroesophageal varices in cirrhotic patients.

Capsule endoscopy--not just for the small bowel: a review

Video capsule endoscopy is being increasingly used to investigate the esophagus and colon as well as the small bowel. With the advancement of technology used in capsule endoscopy there have been marked improvements in diagnostic rates for colon capsule endoscopy in the detection of colonic polyps and colorectal cancer. It is also being increasingly used in the field if inflammatory bowel disease to investigate for mucosal inflammation and could potentially be used to assess mucosal healing. It also has role in completing the evaluation of colonic pathology in those in whom colonoscopy is incomplete. Esophageal capsule is preferred by patients over esophagogastroduodenoscopy (EGD) but as yet does not rival EGD in terms of diagnostic accuracy however the advent of magnetically steerable capsules may improve this. This review covers advances in the field of colon and esophageal capsule endoscopy; it covers diagnostic capabilities of these 2 tools as well as technical aspects of both procedures and preparation.

Current status of capsule endoscopy through a whole digestive tract

More than a decade has passed since small-bowel capsule endoscopy (CE) was first reported. Small-bowel CE is a non-invasive tool that allows visualization of the entire small-intestinal mucosa and facilitates detection of small-intestinal abnormalities. Several studies have shown benefit of small-bowel CE for certain disorders. Because it is non-invasive, CE has been applied to other organs including the esophagus, stomach, and colon. The main indications for esophageal CE (ECE) are screening for gastroesophageal reflux disease/Barrett's esophagus, and esophageal varices. However, the clinical benefit of ECE is unconfirmed. Magnetically guided CE (MGCE) was developed to visualize the gastric mucosa. MGCE is a new concept with room for improvement of capsule navigation and the preparation protocol. Recently, two new small-bowel CE tools were released. First-generation colon CE (CCE-1) has moderate sensitivity and specificity compared with colonoscopy for colorectal neoplasia surveillance. To obtain higher accuracy, a second-generation CCE (CCE-2) was developed with a high sensitivity for detecting clinically relevant polypoid lesions. A possible application of CCE is for inflammatory bowel disease. In the near future, CE may include diagnostic and therapeutic functions such as magnifying endoscopy systems, targeted biopsy forceps, and drug delivery systems.

A pilot study of capsule endoscopy after a standard meal for the detection and grading of oesophageal varices in cirrhotic patients

BACKGROUND

Capsule endoscopy has been proposed as an alternative to fibreoptic endoscopy for oesophageal varices evaluation in cirrhotics. However, it shows only moderate sensitivity compared to fibreoptic endoscopy.

AIM

To compare post-meal capsule endoscopy to fibreoptic endoscopy, based on the hypothesis that meal-induced increase of portal pressure can enhance its sensitivity.

METHODS

Twenty-five patients were submitted to fibreoptic endoscopy and, after a standard meal, capsule endoscopy.

RESULTS

Post-meal capsule endoscopy detected varices in the 18 patients in whom fibreoptic endoscopy detected varices plus 3 more subjects (sensitivity 100%, specificity 70%); large varices in the 4 patients in whom fibreoptic endoscopy graded varices as large, plus 5 more subjects; red markers in the 5 patients in whom fibreoptic endoscopy detected red markers, plus 3 more subjects. High-risk varices were identified in 11 patients by post-meal capsule endoscopy and in 10 by fibreoptic endoscopy (sensitivity 100%, specificity 93.8%).

CONCLUSIONS

Post-meal capsule endoscopy identified more varices, large varices and red markers than fibreoptic endoscopy. The two methods detected similar proportions of high-risk varices. These data suggest that a standard meal can enhance the sensitivity of capsule endoscopy in the detection and grading of oesophageal varices in cirrhotics.

Capsule endoscopy for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis

BACKGROUND

Current guidelines recommend performance of oesophago-gastro-duodenoscopy at the time of diagnosis of hepatic cirrhosis to screen for oesophageal varices. These guidelines require people to undergo an unpleasant invasive procedure repeatedly with its attendant risks, despite the fact that half of the people do not have identifiable oesophageal varices 10 years after the initial diagnosis of cirrhosis. Video capsule endoscopy is a non-invasive test proposed as an alternative method for the diagnosis of oesophageal varices.

OBJECTIVES

To determine the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices in children or adults with chronic liver disease or portal vein thrombosis, irrespective of the aetiology. To investigate the accuracy of capsule endoscopy as triage or replacement of oesophago-gastro-duodenoscopy.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register (October 2013), MEDLINE (Ovid SP) (1950 to October 2013), EMBASE (Ovid SP) (1980 to October 2013), ACP Journal Club (Ovid SP) (1991 to October 2013), Database of Abstracts of Reviews of Effects (DARE) (Ovid SP) (third quarter), Health Technology Assessment (HTA) (Ovid SP) (third quarter), NHS Economic Evaluation Database (NHSEED) (Ovid SP) (third quarter), and Science Citation Index Expanded (SCI-EXPANDED) (ISI Web of Knowledge) (1955 to October 2013). We applied no language or document type restrictions.

SELECTION CRITERIA

Studies that evaluated the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices using oesophago-gastro-duodenoscopy as the reference standard in children or adults of any age, with chronic liver disease or portal vein thrombosis.

DATA COLLECTION AND ANALYSIS

We followed the available guidelines provided in the Cochrane Handbook for Diagnostic Test of Accuracy Reviews. We calculated the pooled estimates of sensitivity and specificity using the bivariate model due to the absence of a negative correlation in the receiver operating characteristic (ROC) space and of a threshold effect.

MAIN RESULTS

The search identified 16 eligible studies, in which only adults with cirrhosis were included. In one study, people with portal thrombosis were also included. We classified most of the studies at high risk of bias for the 'Participants selection' and the 'Flow and timing' domains. One study assessed the accuracy of capsule endoscopy for the diagnosis of large (high-risk) oesophageal varices. In the remaining15 studies that assessed the accuracy of capsule endoscopy for the diagnosis of oesophageal varices of any size in people with cirrhosis, 936 participants were included; the pooled estimate of sensitivity was 84.8% (95% confidence interval (CI) 77.3% to 90.2%) and of specificity 84.3% (95% CI 73.1% to 91.4%). Eight of these studies included people with suspected varices or people with already diagnosed or even treated varices, or both, introducing a selection bias. Seven studies including only people with suspected but unknown varices were at low risk of bias; the pooled estimate of sensitivity was 79.7% (95% CI 73.1% to 85.0%) and of specificity 86.1% (95% CI 64.5% to 95.5%). Six studies assessed the diagnostic accuracy of capsule endoscopy for the diagnosis of large oesophageal varices, associated with a higher risk of bleeding; the pooled sensitivity was 73.7% (95% CI 52.4% to 87.7%) and of specificity 90.5% (95% CI 84.1% to 94.4%). Two studies also evaluated the presence of red marks, which are another marker of high risk of bleeding; the estimates of sensitivity and specificity varied widely. Two studies obtained similar results with the use of a modified device as index test (string capsule). Due to the absence of data, we could not perform all planned subgroup analyses. Interobserver agreement in the interpretation of capsule endoscopy results and any adverse event attributable to capsule endoscopy were poorly assessed and reported. Only four studies evaluated the interobserver agreement in the interpretation of capsule endoscopy results: the concordance was moderate. The participants' preferences for capsule endoscopy or oesophago-gastro-duodenoscopy were reported differently but seemed in favour of capsule endoscopy in nine of 10 studies. In 10 studies, participants reported some minor discomfort on swallowing the capsule. Only one study identified other significant adverse events, including impaction of the capsule due to previously unidentified oesophageal strictures in two participants. No adverse events were reported as a consequence of the reference standard.

AUTHORS' CONCLUSIONS

We cannot support the use of capsule endoscopy as a triage test in adults with cirrhosis, administered before oesophago-gastro-duodenoscopy, despite the low incidence of adverse events and participant reports of being better tolerated. Thus, we cannot conclude that oesophago-gastro-duodenoscopy can be replaced by capsule endoscopy for the detection of oesophageal varices in adults with cirrhosis. We found no data assessing capsule endoscopy in children and in people with portal thrombosis.

Oesophageal capsule endoscopy versus oesophago-gastroduodenoscopy for the diagnosis of recurrent varices: a prospective multicentre study

BACKGROUND

Oesophago-gastroduodenoscopy is the standard method for the diagnosis of recurrent oesophago-gastric varices after endoscopic treatment and eradication. The aim of this study was to evaluate the PillCam Eso capsule endoscopy in this setting.

METHODS

Prospective, multicentre study in which patients with history of oesophageal varices treated by band ligation underwent PillCam Eso capsule and oesophago-gastroduodenoscopy. Capsule recordings were blindly read by two endoscopists. Indication for a new prophylactic treatment and patient satisfaction were determined for both procedures.

RESULTS

80 patients (80% males, mean age: 57±12 years) were included, after a median delay of 16 months from last endoscopic treatment. Recurrent oesophageal varices requiring a new prophylactic treatment were detected in 26 patients (32.5%). The mean oesophageal transit time of the capsule was 153 s (range 2-930 s). Capsule sensitivity, specificity, negative and positive predictive values for indication of new prophylactic treatments were 65%, 83%, 83%, and 65%, respectively. Capsule adequately classified 77.5% of the patients for prophylaxis indication. Inter-observer concordance for capsule readings was 88% for the prophylaxis indication.

CONCLUSION

This study demonstrates that accuracy of PillCam Eso capsule for the diagnosis of recurrent oesophageal varices after endoscopic eradication is suboptimal. PillCam Eso capsule might therefore be proposed in patients unable or unwilling to undergo oesophago-gastroduodenoscopy.

Is small-bowel capsule endoscopy effective for diagnosis of esophagogastric lesions related to portal hypertension?

BACKGROUND AND AIM

Effectiveness of capsule endoscopy (CE) for screening the small bowel in patients with portal hypertension (PHT) has been reported. However, few reports discuss CE detection of specific esophagogastric lesions related to PHT. Thus, we assessed whether CE is useful for detecting such lesions.

METHODS

One hundred nineteen consecutive patients with PHT comprised the study group. All had undergone esophagogastroduodenoscopy (EGD) prior to CE. The diagnostic yield of CE for esophageal varices (EVs), gastric varices (GVs), and portal hypertensive gastropathy (PHG) was evaluated. In addition, diagnostic yield in relation to form, location of the varices, grade, and extent of PHG was evaluated.

RESULTS

EVs were found by EGD in 71 patients. The overall diagnostic yield of CE for EVs was 72% (51/71). The diagnostic yield was significantly greater for F2/F3 EVs than for F1 EVs (87% vs 61%, P = 0.03). The diagnostic yield was significantly greater for Lm/Ls EVs than for Li EVs (85% vs 55%, P = 0.01). The diagnostic yield was significantly greater for locus superior/locus medialis EVs than for locus inferior EVs (85% vs 55%, P = 0.01). GVs were found by EGD in 29 patients. Only one case was detected by CE. PHG was found by EGD in 35 patients. The diagnostic yield of CE for PHG was 69% (24/35). There was no difference in diagnostic yield between cases of severe and mild PHG (82% vs 63%, P = 0.44). Diagnostic yield of CE for PHG in the gastric body was significantly greater than that in the fundus (100% vs 48%, P = 0.0009).

CONCLUSION

CE is reliable for diagnosis of F2/F3 and/or Lm/Ls EVs and of PHG in the gastric body.

Management of varices in patients with cirrhosis

Variceal bleeding remains a life-threatening condition with a 6-week mortality rate of ∼20%. Prevention of variceal bleeding can be achieved using nonselective β-blockers (NSBBs) or endoscopic band ligation (EBL), with NSBBs as the first-line treatment. EBL should be reserved for cases of intolerance or contraindications to NSBBs. Although NSBBs cannot be used to prevent varices, if the hepatic venous pressure gradient (HVPG) is ≤10 mmHg, prognosis is excellent. Survival after acute variceal bleeding has improved over the past three decades, but patients with Child-Pugh grade C cirrhosis remain at greatest risk. Vasoactive drugs combined with endoscopic therapy and antibiotics are the best therapeutic strategy for these patients. Transjugular intrahepatic portosystemic shunts (TIPS) should be used in patients with uncontrolled bleeding or those who are likely to have difficult-to-control bleeding. Rebleeding from varices occurs in ∼60% of patients 1-2 years after the initial bleeding episode, with a mortality rate of 30%. Secondary prophylaxis should start at day 6 after initial bleeding using a combination of NSBBs and EBL. TIPS with polytetrafluoroethylene-covered stents are the preferred option in patients who fail combined treatment with NSBBs and EBL. Despite the improvement in patient survival, further studies are needed to direct the management of patients with gastro-oesophageal varices and variceal bleeding.

Platelet count/spleen diameter ratio for non-invasive diagnosis of oesophageal varices: is it useful in compensated cirrhosis?

AIM

To assess the diagnostic accuracy of the platelet count/spleen diameter ratio for identification of oesophageal varices and/or hypertensive gastropathy in patients with compensated cirrhosis.

METHODS

Platelet count/spleen diameter ratio was calculated in 87 consecutive patients with compensated cirrhosis. A new cut-off with the highest sensitivity and specificity for the presence/absence of oesophageal varices and/or hypertensive gastropathy was identified. Performance of the platelet count/spleen diameter ratio considering previously reported cut-off values were then tested in our population.

RESULTS

A platelet count/spleen diameter ratio <936.4 had the best sensitivity and specificity for the diagnosis of oesophageal varices and for all endoscopic findings of portal hypertension. A value lower than 936.4 allowed identification of 64.5% of patients with oesophageal varices and 66.7% of patients with any sign of portal hypertension; a value higher than 936.4 excluded oesophageal varices in 64.3% of patients and any sign of portal hypertension in 68.6% of patients.

CONCLUSIONS

In patients with compensated cirrhosis, the platelet count/spleen diameter ratio is not a useful parameter to avoid unnecessary upper endoscopy, independently of the cut-off.

String capsule endoscopy for screening and surveillance of esophageal varices in patients with cirrhosis

BACKGROUND

EGD is the gold standard for the screening and surveillance of esophageal varices. A less invasive, safer and sedationless alternative procedure is needed.

OBJECTIVE

To assess the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) as well as the beyond the chance agreement (kappa index), of string capsule endoscopy (SCE) in the diagnosis of esophageal varices.

METHODS

Cirrhotic patients underwent string capsule endoscopy (SCE) and EGD for screening and surveillance purposes. Varices were graded at EGD and SCE as small, medium and large. Descriptors at SCE were added as follows: PLUS, for the presence of red wale signs or, MINUS for their absence, irrespective of the estimated variceal size. Clinically significant varices were defined by their size (medium/large at either EGD or SCE) and/or, the PLUS descriptor irrespective of the estimated size at SCE. Sensitivity, specificity, PPV, NPV, accuracy and kappa index were calculated. Procedure time, procedure-related discomfort and patient's preference were documented.

RESULTS

100 patients (33 for screening and 67 for surveillance) were enrolled. The sensitivity and specificity of SCE for clinically significant varices when using the PLUS/MINUS descriptors were 82% and 90%, respectively with a PPV of 84% and NPV of 89% and a kappa of 0.73.

CONCLUSION

String capsule endoscopy had an acceptable sensitivity and specificity for the diagnosis of clinically significant esophageal varices but the lack of air insufflation still hampers its correlation with the grading used with EGD.

Capsule endoscopy is not as accurate as esophagogastroduodenoscopy in screening cirrhotic patients for varices

BACKGROUND & AIMS

Esophagogastroduodenoscopy (EGD) is the standard technique for screening cirrhotic patients for high-risk varices and other significant upper gastrointestinal lesions (HRVLs). We investigated whether esophageal capsule endoscopy (ECE) is as convenient and accurate as EGD for the detection of HRVLs.

METHODS

We analyzed data from 65 cirrhotic patients without prior upper gastrointestinal bleeding who were examined for varices and HRVLs by ECE and EGD (both procedures were performed on the same day). EGD was performed by 2 physicians (75% of patients were unsedated) who used standard grading for esophageal and gastric varices, portal hypertensive gastropathy, and HRVLs. Coded capsule tracings were read by 2 investigators, blinded to the EGD findings, using standard grading.

RESULTS

The median procedure time for EGD (with or without biopsy collection) was 3 minutes, compared with 20 minutes for ECE. The overall accuracy for diagnosis of esophageal varices was 63.2% ± 5.9%; for detection of esophageal varices red marks was 68.8% ± 5.4%; and for diagnosis of other HRVLs was 51.5% ± 4.2%. The interobserver agreement in the diagnosis of esophageal varices was 90.8%; in the detection of esophageal varices red marks was 86.2%; and in the diagnosis of other HRVLs was 7.3%.

CONCLUSIONS

ECE is not as accurate as EGD in the diagnosis of esophageal varices and red markings or in grading esophageal varices. Moreover, ECE had poor accuracy in grading portal hypertensive gastropathy and detecting ulcers, gastric varices, and other significant upper gastrointestinal lesions. It took significantly longer to perform ECE and interpret the results than for EGD. These findings do not support ECE as a preferred tool for screening esophageal varices and HRVLs.

Influence of operator experience and reporting time on the accuracy of esophageal capsule endoscopy screening for varices

Conflicting data exist concerning the accuracy of esophageal capsule endoscopy (ECE) for the screening of varices. No study has examined the influence of operator factors on the accuracy of ECE reporting. The primary aims of this study were, therefore, to examine how operator experience with esophagogastroduodenoscopy (EGD) and operator reporting times of capsule videos influenced test accuracy. Twelve cirrhotic patients presenting for EGD had same-day ECE performed. The gold standard for variceal grade was determined using a panel of experienced endoscopists. Six novice capsule endoscopists, blinded to results of EGD, subsequently reported capsule videos for each of the 12 patients.Novice capsule endoscopists accurately identified high-risk varices. The mean area under the receiver operating characteristic curve for identifying high-risk varices for the six operators was 0.88 ±/-0.14. The mean sensitivity, specificity, positive, and negative predictive values for identifying high-risk varices for the six operators were 83%, 93%, 82%, and 97%, respectively. Years of prior EGD experience were not associated with accuracy of capsule reporting (OR = 0.9, 95% CI [0.74, 1.08]; p = .26). Time spent reporting capsule videos was associated with accuracy of capsule reporting for high-risk varices using British Society of Gastroenterology criteria (OR = 1.33, 95% CI [1.05, 1.08]; p = .018). Novice capsule endoscopists are able to accurately identify high-risk esophageal varices. Time taken to report capsule videos, but not amount of prior EGD experience, influenced capsule report accuracy. These findings may have implications for the design of further trials and the cost-effectiveness of ECE screening of varices.

Towards noninvasive detection of oesophageal varices

Current guidelines recommend that all cirrhotic patients should undergo screening endoscopy at diagnosis to identify patients with varices at high risk of bleeding who will benefit from primary prophylaxis. This approach places a heavy burden upon endoscopy units and the repeated testing over time may have a detrimental effect on patient compliance. Noninvasive identification of patients at highest risk for oesophageal varices would limit investigation to those most likely to benefit. Upper GI endoscopy is deemed to be the gold standard against which all other tests are compared, but is not without its limitations. Multiple studies have been performed assessing clinical signs and variables relating to liver function, variables relating to liver fibrosis, and also to portal hypertension and hypersplenism. Whilst some tests are clearly preferable to patients, none appear to be as accurate as upper GI endoscopy in the diagnosis of oesophageal varices. The search for noninvasive tests continues.

Esophageal Capsule Endoscopy for Screening Esophageal Varices among Japanese Patients with Liver Cirrhosis

Purpose. Although esophageal capsule endoscopy (ECE) is reportedly useful in the diagnosis of esophageal varices (EV), few reports have described the benefits of this technique in Asian countries. The present paper evaluates the usefulness of ECE for diagnosing EV in Japanese patients with cirrhosis. Methods. We examined 29 patients with cirrhosis (20 males and 9 females; mean age 60 years; Child-Pugh classification A/B/C; 14/14/1) using ECE followed by esophagogastroduodenoscopy (EGD). High-risk EV were defined as F2 and/or RC2 and above. Results. The sensitivity and specificity of ECE for the diagnosis of high-risk EV were 92% and 80%, respectively. Conclusions. The findings showed that ECE is a highly sensitive method of diagnosing high-risk EV that requires endoscopic or pharmacological therapy. Thus, ECE might be a useful method for the screening and followup of EV in patients with cirrhosis.

Detection and grading of esophageal varices on liver CT: comparison of standard and thin-section multiplanar reconstructions in diagnostic accuracy

OBJECTIVE

The objective of our study was to evaluate the performance of liver CT in the diagnosis of esophageal varices in patients with cirrhosis and to determine whether thin-section multiplanar reconstructions (MPRs) improve accuracy.

MATERIALS AND METHODS

We identified 109 patients with cirrhosis who underwent endoscopy within 10 weeks after dual-phase liver MDCT supplemented with thin-section axial and coronal portal venous phase reconstructions. Two blinded radiologists independently evaluated each CT examination for the presence and sizes of varices using standard 5-mm axial versus 1- to 3-mm multiplanar images in separate sessions. Sensitivity, specificity, and predictive value calculations and receiver operating characteristic analysis were performed using endoscopy as the reference standard. Interobserver variability and correlation of CT size to variceal grade were assessed.

RESULTS

Twenty-six cases of high-risk esophageal varices were identified; all except two were detected on CT by one of the readers on standard 5-mm images. For both readers, sensitivity and negative predictive value (NPV) for the discrimination of high-risk varices using a criterion of 2 mm or greater were nearly the same for the standard 5-mm images versus the 1- to 3-mm multiplanar images (sensitivity and NPV: reader 1, 96% and 98% vs 96% and 99%; reader 2, and 89% and 95% vs 89% and 96%, respectively). Standard 5-mm images yielded a lower specificity for high-risk esophageal varices than the thin-section multiplanar images, and this difference was statistically significant for reader 2. Substantial interobserver agreement was noted for both esophageal varices detection and size measurements.

CONCLUSION

Standard liver CT is sensitive for the detection of high-risk varices and deserves further investigation as a potential cost-effective screening tool for the evaluation of patients with cirrhosis. The addition of 1- to 3-mm MPRs may increase specificity for risk stratification based on size measurements.

Noninvasive assessment of portal hypertension in patients with cirrhosis

Severe portal hypertension is responsible for complications and death. Although measurement of the hepatic venous pressure gradient is the most accurate method for evaluating the presence and severity of portal hypertension, this technique is considered invasive and is not routinely performed in all centers. Several noninvasive techniques have been proposed to measure portal hypertension. Certain methods evaluate elements related to the pathogenesis of portal hypertension through the measurement of hyperkinetic syndrome, for example, or they investigate the development of hepatic fibrosis through the measurement of increased intrahepatic vascular resistance. Other methods evaluate the clinical consequences of portal hypertension, such as the presence of esophageal varices or the development of portosystemic shunts. Methods evaluating increased hepatic vascular resistance are fairly accurate and mainly involve the detection of hepatic fibrosis by serum markers and transient elastography. The radiological assessment of hyperkinetic syndrome probably has value but is still under investigation. The assessment of severe portal hypertension by the presence of varices may be performed with simple tools such as biological assays, computed tomography, and esophageal capsules. More sophisticated procedures seem promising but are still under development. Screening tools for large populations must be simple, whereas more complicated procedures could help in the follow-up of already diagnosed patients. Although most of these noninvasive methods effectively identify severe portal hypertension, methods for diagnosing moderate portal hypertension need to be developed; this shows that further investigation is needed in this field.

Oesophageal varices in cirrhotic patients: from variceal screening to primary prophylaxis of the first oesophageal variceal bleeding

Bleeding from oesophageal varices is still a lethal complication in cirrhotic patients with portal hypertension. Approximately 5-10% of patients with cirrhosis will develop oesophageal varices per year, and about 25-30% of cirrhotic patients with oesophageal varices and without previous variceal haemorrhage will bleed from ruptured varices. To date, data on preventing the formation/growth of oesophageal varices (preprimary prophylaxis) are conflicting, with insufficient evidence to use β-blockers. There is evidence for the need for primary prophylaxis, and both β-blockers and endoscopic variceal ligation have shown the same efficacy in preventing first bleeding, but which one to prefer is still controversial. The present article reviews the established and potential therapeutic strategies for preventing the development and rupture of oesophageal varices.

Defining the threshold: new data on the ability of capsule endoscopy to discriminate the size of esophageal varices

BACKGROUND

Endoscopy (esophagogastroduodenoscopy, EGD) to screen for esophageal varices (EV) is recommended in patients with portal hypertension. Reports indicate that capsule endoscopy (CE) is capable of identifying large/medium varices (L/MV) when the varix comprises more than 25% of the circumference of the field of view.

AIMS

We evaluated the ability of CE to discriminate the size of EV using this grading scale.

METHODS

Patients underwent CE and EGD on the same day. A blinded investigator interpreted capsule findings. CE labeled EV as L/MV if ≥25% of the lumen circumference was occupied, and small/none for <25%.

RESULTS

A total of 37 patients were enrolled in this prospective, observational study at a single tertiary-care academic center. Three CE were excluded due to rapid esophageal transit time or technical malfunction. Using a 25% threshold, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for EC to discriminate L/MV were 23.5%, 88.2%, 66.7%, and 53.6%, respectively (κ=0.12). Reducing the threshold to 12.5% resulted in sensitivity, specificity, PPV, and NPV of 88.2%, 64.7%, 71.4%, and 84.6%, respectively (κ=0.53). A receiver-operator characteristic (ROC) curve showed a 15% threshold to be optimal in discriminating EV size using CE, resulting in sensitivity, specificity, PPV, and NPV of 76.5%, 82.4%, 81.3%, and 77.8%, respectively (κ=0.59).

CONCLUSIONS

This study indicates that discriminating EV size by the current capsule scale is unreliable. Lowering the grading threshold improved the ability to discriminate EV size by CE. In the proper context, CE is an alternative to EGD to screen for EV.

Capsule endoscopy in portal hypertension

Since the introduction of small bowel capsule endoscopy, and more recently of esophageal capsule endoscopy, these diagnostic tools have become available for the evaluation of the consequences of portal hypertension in the esophagus, stomach, and small intestine. The main advantage of the esophageal and the small bowel capsule is the relatively less invasiveness that could potentially increase patients' adherence to endoscopic screening/surveillance programs. When esophageal capsule endoscopy was compared with traditional gastroscopy, it showed good sensitivity and specificity in recognizing the presence and the size of esophageal varices. However, the results are not consistent among studies, and more data are needed.

Current staging and diagnosis of gastroesophageal varices

Portal hypertension is defined as an increase in hepatic sinusoidal pressure to 6 mm Hg or higher. Cirrhosis is the most common cause of portal hypertension in the western world and results from increased resistance to blood flow at the hepatic sinusoidal level.

Capsule endoscopy in examination of esophagus for lesions after radiofrequency catheter ablation: a potential tool to select patients with increased risk of complications

BACKGROUND

Esophageal injury can result from left atrial radiofrequency ablation (RFA) therapy, with added concern because of its possible relationship to the development of atrial-esophageal (A-E) fistulas.

OBJECTIVE

Evaluate utility of esophageal capsule endoscopy to detect esophageal lesions as a complication of RFA therapy in the treatment of atrial fibrillation (AF).

METHODS

Consecutive patients with AF who underwent left atrial RFA therapy and received capsule endoscopy within 48 hours postablation. Video was reviewed by a single gastroenterologist. The medical records were also reviewed for symptoms immediately postablation and at the 3-month follow-up.

RESULTS

A total of 93 consecutive patients were included and 88 completed the study and were analyzed. The prevalence of esophageal lesions was 17% (15/88 patients). Nine percent (8/88) of these patients had lesions anatomically consistent with the location of the ablation catheter. Six patients with positive capsule findings had symptoms of chest pain (3/6, 50%), throat pain (2/6, 33%), nausea (1/6, 17%), and abdominal pain (1/6, 17%). An additional 24 patients were symptomatic postablation, but with normal capsule findings. All patients with identified lesions by capsule endoscopy received oral proton pump inhibitor therapy, and were instructed to contact the Cleveland Clinic in the event of worsening symptoms. No delayed complications were reported at the 3-month follow-up.

CONCLUSION

This study supports the use of capsule endoscopy as a tool for the detection of esophageal injury post-RFA therapy. PillCam ESO is well tolerated and provides satisfactory images of the areas of interest in the esophagus without potential risk related to insufflation with regular esophagogastroduodenoscopy.

PillCam ESO versus esophagogastroduodenoscopy in esophageal variceal screening: A decision analysis

OBJECTIVES

PillCam ESO has been evaluated as a possible strategy to screen patients with cirrhosis for esophageal varices, but current guidelines recommend patients undergo screening with esophagogastroduodenoscopy (EGD), as it is currently the gold standard. Although recent data have suggested that PillCam ESO may be an acceptable alternative for screening, there is limited data on its cost-effectiveness compared with other screening modalities. This study was performed to compare the cost-effectiveness of PillCam ESO versus EGD for esophageal variceal screening.

METHODS

Markov models were constructed to compare 2 screening strategies: PillCam ESO versus EGD. In each arm, patients were followed for a time horizon of 15 years in 1-year transition intervals. All variables, transition probabilities, and costs were derived from the medical literature, and sensitivity analyses were performed on the different variables in the model.

RESULTS

Base-case analysis shows that PillCam ESO is associated with an average expected cost of $22,589 and an average expected effectiveness measure of 12.81 life-years. EGD is associated with an average expected cost of $23,083 and an average expected effectiveness measure of 12.67 life-years. PillCam ESO was found to dominate EGD as a screening strategy for patients with cirrhosis. Sensitivity analyses found several variables within the model to have influential effects on the results.

CONCLUSIONS

PillCam ESO is the dominant strategy for screening patients with cirrhosis for esophageal varices. However, based on a small difference in costs and effectiveness between each strategy, the results would suggest that PillCam ESO and EGD are essentially equivalent strategies.

[Future prospects in digestive endoscopy: wireless capsule endoscopy]

Since the beginning of the millennium, the development of wireless capsule endoscopy has represented a major technological advance. The capsule is ingested by the patient and images are transmitted via several sensors positioned on the skin of the patient and downloaded in a computer system. The first applications were focused on the exploration of the small bowel which was previously considered as an obscure area for conventional endoscopy. Wireless capsule endoscopy of the small bowel is now an established technique with many acknowledged indications for the diagnosis of obscure bleeding, anemia of presumed digestive origin, Crohn's disease and small bowel tumors. Recently, thanks to technological progresses, novel capsules have been developed for specific segments of the gut namely the oesophagus and the colon. Recent data suggest that these new capsules could have potential applications for the diagnosis of oesophageal varices, Barrett's oesophagus and for the screening and/or surveillance of polyps of the colon. However, further studies are required before such strategies could be approved for clinical use or even replace conventional endoscopic modalities. In the long-term, progresses in signal processing as well as in the miniaturisation of sensors or markers may lead to a new generation of endoscopic robots. This technological breakthrough may ultimately result in new concepts and change current practice of digestive endoscopy.

Capsule endoscopy of the esophagus

Video capsule endoscopy has acquired wide clinical acceptance since its the US Food and Drug Administration approval in 2001. Recently, the technology of video capsule endoscopy has been adapted to other organs in the gastrointestinal tract, including the esophagus and colon. In this review, we discuss esophageal capsule endoscopy (ECE)-the procedure, its indications, contraindications, safety, and future applications. ECE is a minimally invasive procedure that uses special video capsules with ability to acquire images from 2 cameras with high image storing speed of 14 to 18 frames per second. A special ingestion procedure allows for prolonged esophageal transit time and an optimized view of the gastroesophageal junction. ECE has been shown to have moderately high sensitivity and accuracy in the diagnosis and surveillance of Barrett esophagus in patients with gastroesophageal reflux disease but has not demonstrated superiority to esogastroduodenoscopy in cost-effectiveness models. In patients with portal hypertension, ECE has a sensitivity of 63% to 100% for screening of esophageal varices, but does not seem to be superior to esogastroduodenoscopy in its cost-effectiveness. No serious complications have been reported after ECE although a low rate of esophageal capsule retention (0.7% to 2.2%) has been reported, usually because of unsuspected esophageal strictures. Contraindications to capsule endoscopy include known or suspected gastrointestinal and esophageal obstruction, strictures, or fistulas, intestinal pseudoobstruction, and children under 10 years of age. It is expected that improvements in imaging technology will improve the accuracy of ECE with the development of immunological-based and chemical-based diagnostic capabilities.

Capsule endoscopy: progress update and challenges ahead

Capsule endoscopy (CE) enables remote diagnostic inspection of the gastrointestinal tract without sedation and with minimal discomfort. Initially intended for small-bowel endoscopy, modifications to the original capsule have since been introduced for imaging of the esophagus and the colon. This review presents a research update on CE. Emphasis is placed on PillCam SB, PillCam ESO, and PillCam COLON (Given Imaging, Yoqneam, Israel) since the majority of published studies have investigated these devices. Discussion of initial reports on competing devices, such as EndoCapsule (Olympus, Tokyo, Japan) and MiroCam (IntroMedic Co., Seoul, Republic of Korea) are also included. The last section of this review outlines ongoing research and development directed at the identification of capsule location, control of capsule movement and expansion of the capability of microcameras to enhance the diagnostic power of CE. Research efforts aimed at endowing the capsule with a range of functionalities are also discussed, from tissue sampling for biopsy to optical biopsy and, in some cases, actual treatment (interventional CE), so that CE may ultimately replace both diagnostic and interventional flexible endoscopy.

Esophageal capsule endoscopy vs. EGD for the evaluation of portal hypertension: a French prospective multicenter comparative study

OBJECTIVES

Esophagogastroduodenoscopy (EGD) is the standard method for the diagnosis of esophago-gastric varices. The aim of this prospective multicenter study was to evaluate the PillCam esophageal capsule endoscopy (ECE) for this indication.

METHODS

Patients presenting with cirrhotic or noncirrhotic portal hypertension underwent ECEfollowed by EGD at the time of diagnosis. Capsule recordings were blindly read by two endoscopists.

RESULTS

A total of 120 patients (72 males, mean age: 58 years; mean Child-Pugh score: 7.2) were included. Esophageal varices were detected in 74 patients. No adverse event was observed after either EGD or ECE. Seven (6%) patients were unable to swallow the capsule. The mean recording time was 204 s (range 1-876). Sensitivity, specificity, negative predictive value, and positive predictive value of ECE for the detection of esophageal varices were 77%, 86%, 69%, and 90%, respectively. Sensitivity, specificity, negative and positive predictive values of ECE for the indication of primary prophylaxis (esophageal varices > or = grade 2 and/or red signs) were 77, 88, 90, and 75%, respectively, and 85% of the patients were adequately classified for the indication (or not) of prophylaxis. Interobserver concordance for ECE readings was 79.4% for the diagnosis of varices, 66.4% for the grading of varices, and 89.7% for the indication of prophylaxis.

CONCLUSIONS

This large multicenter study confirms the safety and acceptable accuracy of ECE for the evaluation of esophageal varices. ECE might be proposed as an alternative to EGD for the screening of portal hypertension, especially in patients unable or unwilling to undergo EGD.

Meta-analysis of capsule endoscopy in patients diagnosed or suspected with esophageal varices

AIM: To review the literature on capsule endoscopy (CE) for detecting esophageal varices using conventional esophagogastroduodenoscopy (EGD) as the standard.

METHODS: A strict literature search of studies comparing the yield of CE and EGD in patients diagnosed or suspected as having esophageal varices was conducted by both computer search and manual search. Data were extracted to estimate the pooled diagnostic sensitivity and specificity.

RESULTS: There were seven studies appropriate for meta-analysis in our study, involving 446 patients. The pooled sensitivity and specificity of CE for detecting esophageal varices were 85.8% and 80.5%, respectively. In subgroup analysis, the pooled sensitivity and specificity were 82.7% and 54.8% in screened patients, and 87.3% and 84.7% in the screened/patients under surveillance, respectively.

CONCLUSION: CE appears to have acceptable sensitivity and specificity in detecting esophageal varices. However, data are insufficient to determine the accurate diagnostic value of CE in the screen/surveillance of patients alone.

Non-invasive (and minimally invasive) diagnosis of oesophageal varices

Current guidelines recommend screening all cirrhotic patients by endoscopy, to identify patients at risk of bleeding who should undergo prophylactic treatment. However, since the prevalence of varices in cirrhotic patients is variable, universal screening would imply a large number of unnecessary endoscopies and a heavy burden for endoscopy units. In addition, compliance to screening programs may be hampered by the perceived unpleasantness of endoscopy. Predicting the presence of oesophageal varices by non-invasive means might increase compliance and would permit to restrict the performance of endoscopy to those patients with a high probability of having varices. Over the years, several studies have addressed this issue by assessing the potential of biochemical, clinical and ultrasound parameters, transient elastography, CT scanning and video capsule endoscopy. The platelet count/spleen diameter ratio, CT scanning and video capsule endoscopy have shown promising performance characteristics, although none of them is equivalent to EGD. These methods are perceived by patients as preferable to endoscopy and thus might increase adherence to screening programs. Whether this will compensate for the lower sensitivity of these alternative techniques, and ultimately improve the outcomes if more patients undergo screening, is the crucial question that will have to be answered in the future.

Capsule endoscopy: technique and indications

Since it was introduced in 2000, capsule endoscopy has become the gold standard for endoscopic examination of the small bowel in several clinical situations such as obscure gastrointestinal bleeding, suspicion of Crohn's disease, and surveillance of polyposis syndromes. In this technique a miniaturised endoscope, embedded in a swallowable capsule, is propelled through the gut by peristalsis and reaches the right colon in 5-8h. Images captured by the capsule are recorded on a hard drive in a belt worn by the patient. In addition to the extensive literature currently available on small bowel CE, new capsule devices are currently under evaluation for the examination of the colon with the purpose of screening for colorectal cancer, and of the oesophagus for screening for oesophageal varices and Barrett's oesophagus. These latter indications currently remain under evaluation. This review considers the technical aspects of capsule endoscopy and discusses the indications. Issues of safety and tolerance are also discussed.