Capsule endoscopy: Present status and future expectation

Galar - a large multi-label video capsule endoscopy dataset

Video capsule endoscopy (VCE) is an important technology with many advantages (non-invasive, representation of small bowel), but faces many limitations as well (time-consuming analysis, short battery lifetime, and poor image quality). Artificial intelligence (AI) holds potential to address every one of these challenges, however the progression of machine learning methods is limited by the avaibility of extensive data. We propose Galar, the most comprehensive dataset of VCE to date. Galar consists of 80 videos, culminating in 3,513,539 annotated frames covering functional, anatomical, and pathological aspects and introducing a selection of 29 distinct labels. The multisystem and multicenter VCE data from two centers in Saxony (Germany), was annotated framewise and cross-validated by five annotators. The vast scope of annotation and size of Galar make the dataset a valuable resource for the use of AI models in VCE, thereby facilitating research in diagnostic methods, patient care workflow, and the development of predictive analytics in the field.

Clinical Significance of Small-Bowel Mucosal Changes in Liver Cirrhosis Patients With Suspected Small-Bowel Bleeding: A Capsule Endoscopy Study

BACKGROUND AND AIM

Although the type and prevalence of small-bowel lesions in patients with liver cirrhosis have been reported, the clinical significance of their endoscopic features is unclear. We aimed to clarify their association with small-bowel bleeding in liver cirrhosis patients with suspected small-bowel bleeding.

METHODS

We retrospectively included 165 patients with liver cirrhosis (96 men; median age, 73 years) who underwent capsule endoscopy at our institution: 32 without portal hypertensive enteropathy (Grade 0), 101 with inflammatory-like abnormalities (Grade 1), and 32 with vascular lesions (Grade 2). The main outcome measures were the rates of small-bowel bleeding at the initial bleeding episode and rebleeding. Factors associated with Grade 2 portal hypertensive enteropathy were examined.

RESULTS

At the time of initial bleeding, 66% of patients with Grade 2 portal hypertensive enteropathy had small-bowel bleeding, compared with only 3% of those with Grades 0 or 1 portal hypertensive enteropathy. Furthermore, the cumulative rebleeding rate from small-bowel lesions 1 year after the initial bleeding was 33% in patients with Grade 2, compared to 0% in those with Grades 0 and 1. Colorectal angioectasia, Child-Pugh Grade C cirrhosis, and a history of blood transfusion were independent predictors of small-bowel vascular lesions.

CONCLUSION

Our results suggest that patients with colorectal angioectasia, Child-Pugh Grade C cirrhosis, or a history of blood transfusion have a high risk of small-bowel bleeding and should, therefore, be examined via capsule endoscopy.

Commercial Wearables for the Management of People with Autism Spectrum Disorder: A Review

Autism Spectrum Disorder (ASD) necessitates comprehensive management, addressing complex challenges in social communication, behavioral regulation, and sensory processing, for which wearable technologies offer valuable tools to monitor and support interventions. Therefore, this review explores recent advancements in wearable technology, categorizing devices based on executive function, psychomotor skills, and the behavioral/emotional/sensory domain, highlighting their potential to improve ongoing management and intervention. To ensure rigor and comprehensiveness, the review employs a PRISMA-based methodology. Specifically, literature searches were conducted across diverse databases, focusing on studies published between 2014 and 2024, to identify the most commonly used wearables in ASD research. Notably, 55.45% of the 110 devices analyzed had an undefined FDA status, 23.6% received 510(k) clearance, and only a small percentage were classified as FDA Breakthrough Devices or in the submission process. Additionally, approximately 50% of the devices utilized sensors like ECG, EEG, PPG, and EMG, highlighting their widespread use in real-time physiological monitoring. Our work comprehensively analyzes a wide array of wearable technologies, including emerging and advanced. While these technologies have the potential to transform ASD management through real-time data collection and personalized interventions, improved clinical validation and user-centered design are essential for maximizing their effectiveness and user acceptance.

Capsule endoscopy for small bowel bleed: Current update

Small intestine, hitherto an obscure area for endoscopists before 2000, is now easily evaluated non-invasively using capsule endoscopy and invasively by device-assisted enteroscopies. Major advances in understanding the causes and management of small bowel diseases have been in obscure gastrointestinal (GI) bleed, currently re-named as small bowel bleed, after the discovery of capsule endoscopy. The current article is a narrative review of the technology of capsule endoscopy, its advantages and limitations, future perspective and Indian studies on its utility in patients with small bowel bleed. Till date, eight large series reporting 2319 patients with obscure GI bleed (1554 overt and 765 occult) undergoing capsule endoscopy have been reported from India. Overall yield of capsule endoscopy to detect lesions in these studies varied from 43.5% to 90%. The major causes detected in various studies for small bowel bleed include vascular malformation, portal hypertensive enteropathy, ulcer, stricture, tumor, polyps, etc. Hookworm can cause both occult as well as overt small bowel bleed as shown mainly from India. Capsule endoscopy has also been quite safe in patients with small bowel bleed as despite 0.6% to 15% retention of imaging capsule in Indian studies, development of clinically evident small bowel obstruction has rarely been reported. The major limitations of capsule endoscopy include lack of maneuvrability and therapeutic capability. Research is in progress to overcome some of the limitations of the current capsule endoscopy system. It is concluded that discovery of capsule endoscopy has brought a new paradigm in GI endoscopy and explored a hitherto unexplored area of GI tract, i.e. small bowel that continued to be a black box for the endoscopists.

The Association of Iron Intake and Hypertension, Does Iron Intake Decrease Blood Pressure?

Previous studies reported that iron may have an indispensable role in the risk of hypertension (HTN). However, the result of the studies on the relationship between iron and risk of HTN is inconsistent. This study aimed to assess the association between the association of dietary iron intake and HTN in the Iranian population. This case-control study was conducted on 4184 people aged 35 to 70, including 1239 people with HTN and 2945 people with normal blood pressure (BP) in Sabzevar, Iran. Dietary intake was assessed using a food frequency questionnaire (FFQ). The Nutritionist IV software was used in terms of the assessment of dietary intake of iron. An inverse association was found between iron intake and HTN (OR = 0.97, CI 95%: 0.94-0.99, P = 0.04). The association remained significant after adjustment for age, gender, smoking, drinking alcohol, calorie intake, and BMI (OR = 0.94, CI 95%: 0.89-0.98, P = 0.01). As a conclusion, iron intake was inversely associated with HTN. Further longitudinal studies on the effect of iron intake on BP are required to confirm this finding.

Development and validation of a deep learning system for detection of small bowel pathologies in capsule endoscopy: a pilot study in a Singapore institution

INTRODUCTION

Deep learning models can assess the quality of images and discriminate among abnormalities in small bowel capsule endoscopy (CE), reducing fatigue and the time needed for diagnosis. They serve as a decision support system, partially automating the diagnosis process by providing probability predictions for abnormalities.

METHODS

We demonstrated the use of deep learning models in CE image analysis, specifically by piloting a bowel preparation model (BPM) and an abnormality detection model (ADM) to determine frame-level view quality and the presence of abnormal findings, respectively. We used convolutional neural network-based models pretrained on large-scale open-domain data to extract spatial features of CE images that were then used in a dense feed-forward neural network classifier. We then combined the open-source Kvasir-Capsule dataset (n = 43) and locally collected CE data (n = 29).

RESULTS

Model performance was compared using averaged five-fold and two-fold cross-validation for BPMs and ADMs, respectively. The best BPM model based on a pre-trained ResNet50 architecture had an area under the receiver operating characteristic and precision-recall curves of 0.969±0.008 and 0.843±0.041, respectively. The best ADM model, also based on ResNet50, had top-1 and top-2 accuracies of 84.03±0.051 and 94.78±0.028, respectively. The models could process approximately 200-250 images per second and showed good discrimination on time-critical abnormalities such as bleeding.

CONCLUSION

Our pilot models showed the potential to improve time to diagnosis in CE workflows. To our knowledge, our approach is unique to the Singapore context. The value of our work can be further evaluated in a pragmatic manner that is sensitive to existing clinician workflow and resource constraints.

A systematic review on diagnosis and treatment of gastrointestinal diseases by magnetically controlled capsule endoscopy and artificial intelligence

Background

Magnetically controlled capsule endoscopy (MCCE) is a non-invasive, painless, comfortable, and safe equipment to diagnose gastrointestinal diseases (GID), partially overcoming the shortcomings of conventional endoscopy and wireless capsule endoscopy (WCE). With advancements in technology, the main technical parameters of MCCE have continuously been improved, and MCCE has become more intelligent.

Objectives

The aim of this systematic review was to summarize the research progress of MCCE and artificial intelligence (AI) in the diagnosis and treatment of GID.

Data Sources and Methods

We conducted a systematic search of PubMed and EMBASE for published studies on GID detection of MCCE, physical factors related to MCCE imaging quality, the application of AI in aiding MCCE, and its additional functions. We synergistically reviewed the included studies, extracted relevant data, and made comparisons.

Results

MCCE was confirmed to have the same performance as conventional gastroscopy and WCE in detecting common GID, while it lacks research in detecting early gastric cancer (EGC). The body position and cleanliness of the gastrointestinal tract are the main factors affecting imaging quality. The applications of AI in screening intestinal diseases have been comprehensive, while in the detection of common gastric diseases such as ulcers, it has been developed. MCCE can perform some additional functions, such as observations of drug behavior in the stomach and drug damage to the gastric mucosa. Furthermore, it can be improved to perform a biopsy.

Conclusion

This comprehensive review showed that the MCCE technology has made great progress, but studies on GID detection and treatment by MCCE are in the primary stage. Further studies are required to confirm the performance of MCCE.

Computer vision-based solutions to overcome the limitations of wireless capsule endoscopy

Endoscopic investigation plays a critical role in the diagnosis of gastrointestinal (GI) diseases. Since 2001, Wireless Capsule Endoscopy (WCE) has been available for small bowel exploration and is in continuous development. Over the last decade, WCE has achieved impressive improvements in areas such as miniaturisation, image quality and battery life. As a result, WCE is currently a very useful alternative to wired enteroscopy in the investigation of various small bowel abnormalities and has the potential to become the leading screening technique for the entire gastrointestinal tract. However, commercial solutions still have several limitations, namely incomplete examination and limited diagnostic capacity. These deficiencies are related to technical issues, such as image quality, motion estimation and power consumption management. Computational methods, based on image processing and analysis, can help to overcome these challenges and reduce both the time required by reviewers and human interpretation errors. Research groups have proposed a series of methods including algorithms for locating the capsule or lesion, assessing intestinal motility and improving image quality.In this work, we provide a critical review of computational vision-based methods for WCE image analysis aimed at overcoming the technological challenges of capsules. This article also reviews several representative public datasets used to evaluate the performance of WCE techniques and methods. Finally, some promising solutions of computational methods based on the analysis of multiple-camera endoscopic images are presented.

Small-sized versus standard magnetic capsule endoscopy in adults: a two-center, double-blinded randomized controlled trial

BACKGROUND : Certain patients experience difficulty swallowing a video capsule endoscopy (VCE) device owing to its relatively large size. The newly developed small-sized magnetically controlled capsule endoscopy (MCE) device is the smallest VCE device ever reported. We aimed to evaluate the performance of the small-sized MCE device in terms of ingestion and examination efficacy. METHODS : Patients in two centers were prospectively enrolled and randomized to the small-sized or standard MCE groups. Differences in capsule ingestion difficulties, visualization of the gastrointestinal tract, and capsule transit times were compared. RESULTS : 96 patients were enrolled (48 in each group). In the small-sized MCE group, the mean (SD) difficulty score and time to swallow the capsule, and success rate for swallowing the capsule at the first attempt were 0.6 (1.0), 3.4 (1.3) seconds, and 89.6 %, which was significant better compared with the standard MCE group with 3.1 (1.7), 12.0 (14.3) seconds and 60.4 %, respectively (all P < 0.001). Visualization of the esophagus, stomach, and small bowel were comparable between the two groups. The small-sized MCE group had a significantly shorter gastric transit time (49.4 minutes vs. 66.2 minutes; P = 0.04) and longer small-bowel transit time (5.8 hours vs. 5.0 hours; P = 0.045). CONCLUSIONS : The small-sized MCE device is feasible and safe for gastrointestinal examination, alleviating difficulties in capsule ingestion, improving gastric emptying under magnetic control, and prolonging the small-bowel transit time.

Developing sensor materials for screening intestinal diseases

Intestinal diseases that have high mortality and morbidity rates and bring huge encumbrance to the public medical system and economy worldwide, have always been the focus of clinicians and scientific researchers. Early diagnosis and intervention are valuable in the progression of many intestinal diseases. Fortunately, the emergence of sensor materials can effectively assist clinical early diagnosis and health monitoring. By accurately locating the lesion and sensitively analyzing the level of disease markers, these sensor materials can help to precisely diagnose the stage and state of lesions, thereby avoiding delayed treatment. In this review, we provide comprehensive and in-depth knowledge of diagnosing and monitoring intestinal diseases with the assistance of sensor materials, particularly emphasizing their design and application in bioimaging and biodetection. This review is dedicated to conveying practical applications of sensor materials in the intestine, critical analysis of their mechanisms and applications and discussion of their future roles in medicine. We believe that this review will promote multidisciplinary communication between material science, medicine and relevant engineering fields, thus improving the clinical translation of sensor materials.

Video Capsule Endoscopy in Gastroenterology

Video capsule endoscopy (VCE) is a wireless technology used by gastroenterologists for various indications in their clinical practice. There has been significant improvement in this technology since its start about two decades ago. Specific video capsules have been made to evaluate the small bowel, colon, and esophagus. Now pan-enteric video capsule is available to assess both the small bowel and colon. VCE is a non-invasive procedure that has been tremendously evaluated for various gastrointestinal disorders, particularly small intestinal bleeding. There are specific contraindications and complications of VCE. This procedure has the technical part and video reading part. Newer software programs will come to reduce the reading time. Artificial intelligence is also coming for quick and accurate diagnosis of any positive findings during VCE. VCE is an important diagnostic test in the field of gastroenterology. Although it is an addition to optical endoscopic procedures to visualize the gastrointestinal mucosa, it has advantages and disadvantages.

Clinical features of obscure gastrointestinal bleeding undergoing capsule endoscopy: A retrospective cohort study

Background

Capsule endoscopy has been widely used to investigate obscure gastrointestinal bleeding (OGIB) in the small intestine since its approval in 2001. However, the clinical features of OGIB remain unclear.

Aim

We retrospectively examined the clinical features and risk factors of OGIB in patients who underwent capsule endoscopy in our hospital.

Methods

We included 420 of the 431 patients who underwent capsule endoscopy from June 2014 to May 2021, in whom the small intestine could be observed. We retrospectively compared the clinical features and treatment of OGIB cases, with or without active small bowel bleeding (n = 173), with other cases (n = 247). Patient sex, age, diabetes mellitus, and heart failure histories were matched for the analysis.

Results

The male/female ratio was 247/173 and the average age was 51.54 years. In multivariate analysis, the use of direct oral anticoagulants was significant (P = 0.016), and vascular lesions (P = 0.018) were observed in OGIB cases. When OGIB cases with and without active small bowel bleeding were compared, serum albumin level was lower in cases with active bleeding (P = 0.031). When treatment of OGIB cases were compared, those without vascular lesions could be treated conservatively (P = 0.0047). In the 1:1 propensity score matching analysis, serum creatinine level was elevated in cases of active bleeding (P = 0.029), and cases without vascular lesions were treated conservatively (P = 0.010).

Conclusions

Use of direct oral anticoagulants is frequently associated with OGIB. OGIB patients without vascular lesions may be treated conservatively.

Capsule Endoscopy: Pitfalls and Approaches to Overcome

Capsule endoscopy of the gastrointestinal tract is an innovative technology that serves to replace conventional endoscopy. Wireless capsule endoscopy, which is mainly used for small bowel examination, has recently been used to examine the entire gastrointestinal tract. This method is promising for its usefulness and development potential and enhances convenience by reducing the side effects and discomfort that may occur during conventional endoscopy. However, capsule endoscopy has fundamental limitations, including passive movement via bowel peristalsis and space restriction. This article reviews the current scientific aspects of capsule endoscopy and discusses the pitfalls and approaches to overcome its limitations. This review includes the latest research results on the role and potential of capsule endoscopy as a non-invasive diagnostic and therapeutic device.

Leveraging On-Chip Transistor Switching for Communication and Sensing in Neural Implants and Gastrointestinal Devices

OBJECTIVE

This paper presents a Proof-of-Concept (POC) design and implementation of a biosensing and communication system that can be used for biotelemetry in neural and Gastrointestinal (GI) applications.

METHODS

Our proposed system is based on backscattering from a semi-passive Radio-Frequency-Identification-Device (RFID) implemented using an Application Specific Integrated Circuit (ASIC) in which electronic switching between transistor gates in high and low states create an impedance difference, thereby effectively changing the ASIC's Radar Cross Section (RCS) and thus modulating its backscat-tered field. The ASIC is used in conjunction with a biosensor to measure and transmit vital signs from within the body. With this system, we conducted backscatter propagation experiments through different biological and phantom tissues (in ex-vivo and in-vitro) in the GI and neural environments.

RESULTS

Our results show that the backscattered waveforms can penetrate tissues of various compositions and thicknesses with power received at distances of up to 55 cm away from the RFID ASIC. Furthermore, results from single-and multi-bit biotelemetry measurements showed a high signal fidelity with low Bit-Error-Rate (BER) while being able to resolve varying tissue temperatures measured by the biosensor in our system.

CONCLUSION

We realized a POC system in which on-chip transistor switching in an ASIC can be used to achieve backscatter communication and biosensing. This system is deployable in neural and GI applications.

SIGNIFICANCE

Our findings in this work will provide an important practical basis for the design and development of RFID ASIC for biosensing and biotelemetry in medical applications.

Dysregulation of iron metabolism in cardiovascular diseases: From iron deficiency to iron overload

Iron deficiency and iron overload are the most prevalent and opposite forms of dysregulated iron metabolism that affect approximately 30 percent of the world population, in particularly, elderly and patients with chronic diseases. Both iron deficiency and overload are frequently observed in a wide range of cardiovascular diseases, contributing to the onset and progression of these diseases. One of the devastating seqeulae for iron overload is the induction of ferroptosis, a newly defined form of regulated cell death which heavily impacts cardiac function through ferroptotic cell death in cardiomyocytes. In this review, we will aim to evaluate iron deficiency and iron overload in cardiovascular diseases. We will summarize current therapeutic strategies to tackle iron deficiency and iron overload, major pitfalls of current studies, and future perspectives.

Posture Dynamic Modeling and Stability Analysis of a Magnetic Driven Dual-Spin Spherical Capsule Robot

In order to realize the intervention operation in the unstructured and ample environments such as stomach and colon, a dual-spin spherical capsule robot (DSCR) driven by pure magnetic torque generated by the universal rotating magnetic field (URMF) is proposed. The coupled magnetic torque, the viscoelastic friction torque, and the gravity torque were analyzed. Furthermore, the posture dynamic model describing the electric-magnetic-mechanical-liquid coupling dynamic behavior of the DSCR in the gastrointestinal (GI) tract was established. This model is a second-order periodic variable coefficient dynamics equation, which should be regarded as an extension of the Lagrange case for the dual-spin body system under the fixed-point motion, since the external torques were applied. Based on the Floquet-Lyapunov theory, the stability domain of the DSCR for the asymptotically stable motion and periodic motion were obtained by investigating the influence of the angular velocity of the URMF, the magnetic induction intensity, and the centroid deviation. Research results show that the DSCR can realize three kinds of motion, which are asymptotically stable motion, periodic motion, and chaotic motion, according to the distribution of the system characteristic multipliers. Moreover, the posture stability of the DSCR can be improved by increasing the angular velocity of the URMF and reducing the magnetic induction intensity.

Determinants of non-participation in colon examination following positive stool sample in colorectal cancer screening

BACKGROUND

Social inequalities has been shown for participation in colorectal cancer screening and recently in the initial stool sample blood test. If these differences persist at follow-up colon examination after a positive stool test, it would suggest that social inequality in screening may be greater than the inequality observed in initial stool sample blood test.

METHODS

All data were derived from national registers. Using logistic regression analyses, odds of non-participation for follow-up colon examination were estimated based on age group, educational level, income quartile, immigration status and marital status in men and in women, who had participated in initial stool sample test for blood with a positive result.

RESULTS

Among 20 849 men and 16 565 women invited for follow-up colonoscopy in the period 2014-15, 10.63 and 11.37%, respectively, did not attend. In men, odds of non-participation were higher in the eldest, those with lower income and lower educational level, in immigrants and in singles. Odds ratio (OR) in males of highest income quartile was 0.54 [95% confidence interval (CI) 0.46; 0.63] compared with lowest income quartile. In women, the differences were not as large. OR in females of highest income quartile was 0.73 (95% CI 0.61; 0.87) compared with lowest income quartile.

CONCLUSION

Sociodemographic differences in odds of non-participation exist in follow-up colon examination in the Danish colorectal cancer screening. Differences were evident in all subgroups of the male population. The same patterns were seen in women. Social inequalities in participation for follow-up colon examination can increase overall social inequality and consequently, lead to health disparities.

Rational use of 18F-FDG PET/CT in patients with advanced cutaneous melanoma: A systematic review

18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is increasingly used in patients with advanced melanoma. Immune checkpoint inhibitors and BRAF/MEK-targeted therapy have transformed the therapeutic landscape of metastatic melanoma. Consequently, a need for markers predicting (early) response to treatment and for monitoring treatment (toxicity) has arisen. This systematic review appraises the current literature evidence for rational use of 18F-FDG PET/CT scans in staging, clinical decision-making, treatment monitoring and follow-up in advanced melanoma. 18F-FDG PET/CT has high overall accuracy for detection of distant metastases and is, combined with cerebral MRI, the preferred imaging strategy for staging metastatic melanoma. In contrast, strong evidence supporting the standard use of 18F-FDG PET/CT for predicting and monitoring therapy response and toxicity is currently lacking. Essential for determining the position of 18F-FDG PET/CT during treatment course in advanced melanoma are well-designed studies with standardized scanning protocols, incorporation of clinical parameters and comparison with contrast-enhanced CT alone.

Diagnostic efficacy of double-balloon enteroscopy in patients with suspected isolated small bowel Crohn's disease

BACKGROUND

Owing to the development of double-balloon enteroscopy (DBE) and video capsule endoscopy (VCE) in recent years, direct visualization of the entire small intestinal mucosa has become possible. Because of the nonspecific symptoms and the anatomic location of the small bowel, diagnosis of isolated small bowel Crohn's disease (CD) remains a challenge. The aim of this research was to explore the value of DBE for isolated small bowel CD in situations where routine tests cannot confirm the diagnosis.

METHODS

This study included patients with suspected isolated small bowel CD who were hospitalized in Shengjing Hospital from April 2014 to June 2018. We included patients presenting with chronic diarrhea, abdominal pain, abdominal mass, perianal lesions, and systemic symptoms including weight loss, fever, and anemia after excluding infection factors. Patients with purely colonic CD were excluded from this cohort. Patients with suspected isolated small bowel CD underwent DBE.

RESULTS

In 16/18 patients, pathological findings were detected by DBE. In 12 of the cases, small bowel CD was confirmed. The remaining four patients were diagnosed with small bowel inflammation, duodenal carcinoma, ileum inflammation and small bowel ulcers. However, the diagnosis of CD was confirmed in 14/18 (78%) patients by taking into account the clinical presentation, endoscopic and histological results as well as the experimental treatment. DBE assisted in the diagnosis in 86% (12/14) of the patients.

CONCLUSIONS

In the diagnosis of small bowel CD, DBE is a helpful tool. Before assessment with DBE, clinical features, colonoscopy, and CT were used to initially assess the intestine. According to the lesions indicated by CT, we chose the most appropriate endoscope insertion route, and combined the endoscopic characteristics and pathological results of DBE to confirm the diagnosis.

Effects of Helix Geometry on Magnetic Guiding of Helical Polymer Composites on a Gastric Cancer Model: A Feasibility Study

This study investigates the effects of soft-robot geometry on magnetic guiding to develop an efficient helical mediator on a three-dimensional (3D) gastric cancer model. Four different magnetically active helical soft robots are synthesized by the inclusion of 5-μm iron particles in polydimethylsiloxane matrices. The soft robots are named based on the diameter and length (D2-L15, D5-L20, D5-L25, and D5-L35) with samples having varied helical pitch and weight values. Then, the four samples are tested on a flat surface as well as a stomach model with various 3D wrinkles. We analyze the underlying physics of intermittent magnetomotility for the helix on a flat surface. In addition, we extract representative failure cases of magnetomotility on the stomach model. The D5-L25 sample was the most suitable among the four samples for a helical soft robot that can be moved to a target lesion by the magnetic-flux density of the stomach model. The effects of diameter, length, pitch, and weight of a helical soft robot on magnetomotility are discussed in order for the robot to reach the target lesion successfully via magnetomotility.

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.

Association between hypokalemia and small bowel capsule endoscopy completion rates in patients in South China: A prospective single-center study

BACKGROUND/AIMS

Approximately 20-30% of small bowel capsule endoscopies (SBCEs) do not reach the cecum at the completion of the examination. We aimed to determine whether hypokalemia influences the completion rate and small bowel transit time (SBTT) of SBCE.

PATIENTS AND METHODS

From January to December 2017, 112 patients (18-75 years old) who underwent SBCE were assessed consecutively for enrolment in our study. On the day of the procedure, a blood test was performed prior to capsule ingestion. The completion rate, gastric transit time (GTT), SBTT, and diagnostic yield were recorded for each SBCE.

RESULTS

The SBCE completion rate was lower in the hypokalemia group than that in the normal potassium group (55.6% (15/27) vs. 76.5% (65/85), P = 0.036). The median GTT was 55.5 ± 47.1 min in the hypokalemia group and 46.7 ± 44.5 min in the normal potassium group (P > 0.05). The median SBTT was 412.8 ± 123.3 min in the hypokalemia group and 367.3 ± 172.5 min in the normal potassium group (P > 0.05). The diagnostic yields of the hypokalemia and normal potassium groups were 74.1% and 78.8%, respectively (P = 1.00).

CONCLUSION

Hypokalemia may decrease the SBCE completion rate. Physicians should consider the possibility of hypokalemia after bowel preparation because this condition is not rare. Potassium deficiencies should be rectified prior to performing SBCE procedures to increase the SBCE completion rate.

Meckel's diverticulum diagnosis by video capsule endoscopy: A case report and review of literature

BACKGROUND

Meckel's diverticulum (MD) occurs predominantly in children and adolescents. It is rarely diagnosed in adults. Preoperative diagnosis is difficult due to low sensitivity of the radiological imaging studies. The role of video capsule endoscopy (VCE) in the diagnosis of MD is unknown, and the endoscopic patterns are not defined. We will describe four of our cases of MD evaluated with VCE and make a review of the literature focusing on the endoscopic characteristics.

CASE SUMMARY

We present four cases of MD confirmed by surgery. They were all adult males with ages going from 18 to 50 years, referred to our service from 2004 to 2018, due to obscure gastrointestinal bleeding (OGIB). They had a history of 1 mo to 10 years of overt and occult bleeding episodes. Laboratory blood test showed an iron-deficiency anemia from 4 to 9 g/dL of hemoglobin that required multiple hospitalizations and blood transfusions in all cases. Repeated upper digestive endoscopies and colonoscopies were negative. Small bowel was examined with VCE, which revealed double lumen images in all cases, one with polyps and three with circumferential ulcers in the diverticulum. However, based on VCE findings, preoperative diagnosis of MD was suggested only in two patients. Capsule was retained in one patient, which was recovered with surgery. The anatomopathological report revealed ulcerated ectopic gastric mucosa in all cases.

CONCLUSION

VCE is useful for the diagnosis of MD. However, endoscopic characteristics must be recognized in order to establish preoperative diagnosis.

Clinical Use of Patency Capsule: A Comprehensive Review of the Literature

The patency capsule is a radiopaque, dissolvable diagnostic tool, similar in shape and size to small bowel capsule endoscopes. It was developed to offer a simple, safe, efficient, and accurate evaluation of small bowel functional patency. Although unable to provide direct visual information regarding the presence and location of strictures, masses, or luminal narrowing of the small bowel, a successful patency test minimizes the risk of retention and allows the safe administration of a capsule endoscope. However, its use entails a low risk of potentially harmful adverse events, which in their majority are indolent and resolve spontaneously. Abdominal pain and symptomatic retention are accountable for the majority of reported adverse events, whereas a limited number of reports describe life-threatening complications, namely intestinal obstruction, perforation, and intestinal ischemia. Computed tomography is the modality of choice for the identification of the exact position of an impacted patency capsule, whilst the use of plain abdominal radiographs should be avoided for the evaluation of the patency capsule position, as they provide false information. Hereby, we present a comprehensive review of the available literature regarding the characteristics, indications, clinical use, effectiveness, and adverse events of the patency capsule.10.1093/ibd/izy152_video1izy152.video15777752348001.

Current Status of Interpretation of Small Bowel Capsule Endoscopy

Capsule endoscopy (CE) has revolutionized direct small bowel imaging and is widely used in clinical practice. Remote visualization of bowel images enables painless, well-tolerated endoscopic examinations. Small bowel CE has a high diagnostic yield and the ability to examine the entire small bowel. The diagnostic yield of CE relies on lesion detection and interpretation. In this review, issues related to lesion detection and interpretation of CE have been addressed, and the current status of automated reading software development has been reviewed. Clinical significance of an external real-time image viewer has also been described.

Role of capsule endoscopy in alarm features and non-responsive celiac disease: A European multicenter study

BACKGROUND AND AIM

The role of capsule endoscopy (CE) in established celiac disease (CD) remains unclear. Our objective was to analyze the usefulness of CE in the suspicion of complicated CD.

METHODS

This was a retrospective multicenter study. One hundred and eighty-nine celiac patients (mean age: 46.6 ± 16.6, 30.2% males) who underwent CE for alarm symptoms (n = 86, 45.5%) or non-responsive CD (n = 103, 54.5%) were included. Diagnostic yield (DY), therapeutic impact and safety were analyzed.

RESULTS

Capsule endoscopy was completed in 95.2% of patients (small bowel transit time: 270.5 ± 100.2 min). Global DY was 67.2%, detecting atrophic mucosa (n = 92, 48.7%), ulcerative jejunoileitis (n = 21, 11.1%), intestinal lymphoma (n = 7, 3.7%) and other enteropathies (n = 7, 3.7%, six Crohn's disease cases and one neuroendocrine tumor). The DY of CE was significantly higher in patients presenting with non-responsive disease compared to patients with alarm symptoms (73.8% vs 59.3%, P = 0.035). The new findings of the CE modified management in 59.3% of the cases. There were no major complications.

CONCLUSION

Capsule endoscopy may be a moderately helpful and safe diagnostic tool in the suspicion of complicated CD, modifying the clinical course of these patients.

What defines quality in small bowel capsule endoscopy

Small bowel capsule endoscopy is considered a first-line diagnostic tool for the investigation of small bowel diseases. Gastroenterological and endoscopic societies have proposed and established measures known as quality indicators, quality measures or performance measures for the majority of endoscopic procedures, in order to ensure competence, healthcare quality and define areas requiring improvement. However, there is a paucity of publications describing small bowel capsule endoscopy quality indicators. Hereby, we attempt to identify and describe a number of pre-procedure, intra-procedure and post-procedure quality indicators, regarding process measures in small bowel capsule endoscopy, after a comprehensive review of the literature.

Pathophysiology, Diagnosis, and Management of Chronic Intestinal Pseudo-Obstruction

Chronic intestinal pseudo-obstruction (CIPO) is a rare disorder characterized by an impairment of coordinated propulsive activity in the gastrointestinal (GI) tract, which clinically mimics mechanical intestinal obstruction. CIPO is the most severe and debilitating form of GI dysmotility. CIPO may be primary or be secondary to pathology at any level of the brain-gut axis as well as systemic disease. The clinical features of CIPO are pleomorphic and largely depend on the site and extent of the segment of the GI tract involved. The diagnostic approach includes the need for investigations to exclude mechanical GI obstruction, screening for causes of secondary CIPO and the identification of the disease phenotype as well as the prompt recognition and treatment of complications such as malnutrition and small intestinal bacterial overgrowth. In managing this disorder, a holistic, multidisciplinary approach is needed with judicious use of pharmacotherapeutic agents. While currently there are no specific therapeutic modalities for CIPO, treatment is largely directed at maintaining adequate nutrition and electrolyte balance and enhancing coordinated GI motility. Surgery should be avoided unless advisable for carefully selected patients and may include stoma formation. This narrative review provides a concise overview of the literature on this rare, severe and complex disorder, and highlights the need and areas for further research to improve both diagnostics and therapeutics.

Use of single photon metal artefact reduction in the detection of an impacted capsule endoscope

Wireless capsule endoscopy was introduced over a decade ago and is now a widely used tool in the investigation of gastrointestinal pathologies. Despite its ubiquity, the full profile of indications, contraindications and complications is still being developed. Metal artefact reduction is a software technique which can significantly reduce the artefact produced by metallic objects on CT scans. This case exemplifies a rare but noteworthy complication of capsule endoscopy and highlights a novel application of metal artefact reduction.

Clinical factors related to false-positive rates of patency capsule examination

BACKGROUND

Retention is the most common complication of capsule endoscopy (CE), and is reported to occur in 0-13% of cases. To avoid retention, a PillCam patency capsule (PC) is used in patients with suspected intestinal stenosis. However, a relatively low positive predictive value of the PC examination has been reported previously. The aims of this study were to clarify the accuracy of PC examination and to evaluate clinical factors related to cases of false-positive detection.

METHODS

We performed a retrospective single-center study of 282 consecutive patients referred for PC examination. Patients in which the PC could not pass through the small bowel within 33 h were classified into the 'no patency' group. The 'no patency' group was investigated for evidence of significant stenosis upon further examinations, including CE, double-balloon endoscopy, and small bowel follow-through after PC examination. Clinical factors related to small bowel patency and false-positive cases were evaluated.

RESULTS

We included 161 male (57.1%) and 121 female (42.9%) patients with a mean age of 47.5 ± 17.7 years. Of the 282 patients enrolled, 27 patients exhibited 'no patency' upon PC examination. Multivariate analysis showed that clinical factors related to 'no patency' included Crohn's disease, abdominal symptoms, stenosis upon imaging, and previous abdominal surgery. Upon further examination, nine cases in the 'no patency' group had significant stenosis. Sensitivity, specificity, and negative and positive predictive values of PC examination for detecting small bowel stenosis were 93.8%, 96.6%, 99.6%, and 62.5%, respectively, and the only clinical factor related to false-positive cases was constipation (p < 0.05).

CONCLUSION

We found a relatively low positive predictive value of PC examination and that constipation was related to false-positive results. To extend the implications of CE indications, clinical study focusing on these results is expected.

Multiple gastric erosions diagnosed by means of capsule endoscopy in a dog

CASE DESCRIPTION A 6-year-old spayed female Golden Retriever was evaluated for a 2-week history of progressive hyporexia, signs of abdominal pain, and weight loss. CLINICAL FINDINGS Physical examination findings included mild signs of pain on palpation of the cranial part of the abdomen and a body condition score of 4 (scale, 1 to 9). A CBC revealed mild microcytosis and hypochromasia; results of serum biochemical analysis were within the respective reference ranges, and abdominal ultrasonography revealed no abnormalities. Capsule endoscopy was performed, and numerous gastric erosions and hemorrhages were detected, with rare dilated lacteals in the proximal aspect of the small intestine. TREATMENT AND OUTCOME Treatment was initiated with omeprazole and sucralfate for 6 weeks, and the dog was transitioned to a novel protein diet. Capsule endoscopy was repeated at the end of the initial treatment course and revealed overall improvement, with a few small erosions remaining; medical treatment was continued for an additional 2 weeks. At last follow-up 9 months after treatment ended, the dog was clinically normal. CLINICAL RELEVANCE Capsule endoscopy was useful for initial detection and subsequent reevaluation of gastrointestinal lesions in this patient without a need for sedation or anesthesia. Information obtained in the follow-up evaluation was valuable in identifying a need to extend the duration of medical treatment.

Detection of small-bowel tumours with CT enteroclysis using carbon dioxide and virtual enteroscopy: A preliminary study

PURPOSE

The aim of this prospective study was to evaluate the feasibility, tolerance and performance of virtual enteroscopy (VE) using carbon dioxide for small-bowel distension in patients with suspected small-bowel tumours (SBTs).

PATIENTS AND METHODS

After IRB approval, 17 patients with suspected SBTs were prospectively included. Radiation dose was compared to 34 matched patients (2 for 1) for age, gender and body weight, who had undergone CT-enteroclysis with neutral contrast (CTE). Performance of VE was evaluated through comparison with the current standard of reference, including surgery and/or enteroscopy and/or follow-up.

RESULTS

Tolerance was excellent in 16/17 patients (94%). The radiation dose was lower for VE than for CTE (533 ± 282 vs. 974 ± 505 mGy.cm; p = 0.002). With VE, a total of 25 polyps >5 mm in size were depicted in 12/17 patients. On a per-lesion analysis, sensitivity and positive predictive value of VE were 92.0% and 92.0%, respectively. On a per-segment analysis VE had a sensitivity and specificity of 95.0% and 87.0%, respectively.

CONCLUSION

Our preliminary study suggests that VE is a feasible and well-tolerated technique with high sensitivity and specificity for the diagnosis of SBT.

KEY POINTS

• Virtual enteroscopy is feasible and well tolerated. • Virtual enteroscopy appears to be accurate for detection of small-bowel tumours. • Sensitivity and PPV of virtual enteroscopy is 92.0% and 92.0%. • Radiation dose is lower with virtual enteroscopy compared to MDCT-enteroclysis.

A comparison between capsule endoscopy and double balloon enteroscopy using propensity score-matching analysis in patients with previous obscure gastrointestinal bleeding

BACKGROUND

Recently, diagnosis of obscure gastrointestinal bleeding (OGIB) has improved greatly due to introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE). However, the efficacy of CE over DBE in patients with previous OGIB remains unclear. This study aimed to compare, in terms of diagnostic yield, the efficacy of DBE with that of CE in patients with previous OGIB.

PATIENTS AND METHODS

We enrolled 223 consecutive patients with previous OGIB who were treated between May 2007 and March 2012. We retrospectively evaluated the respective diagnostic yields of CE and DBE in patients with previous OGIB using propensity score-matching analysis. We compared the diagnostic yield of CE with that of DBE.

RESULTS

The diagnostic yields were 41.9% in DBE group and 11.6% in CE group, respectively (p < .01). On logistic regression analysis, DBE was significantly superior to CE after matching (Odds ratio [OR], 4.25; 95% confidence interval [CI], 1.43-12.6; p < .01), even after adjustment for propensity score (OR, 5.65; 95% CI, 1.56?20.5; p < .01).

CONCLUSIONS

Our results indicate that DBE might be more useful and perhaps safer than CE in achieving a positive diagnosis in patients with previous OGIB.

Endoscope field of view measurement

The current International Organization for Standardization (ISO) standard (ISO 8600-3: 1997 including Amendment 1: 2003) for determining endoscope field of view (FOV) does not accurately characterize some novel endoscopic technologies such as endoscopes with a close focus distance and capsule endoscopes. We evaluated the endoscope FOV measurement method (the FOV_WS method) in the current ISO 8600-3 standard and proposed a new method (the FOV_EP method). We compared the two methods by measuring the FOV of 18 models of endoscopes (one device for each model) from seven key international manufacturers. We also estimated the device to device variation of two models of colonoscopes by measuring several hundreds of devices. Our results showed that the FOV_EP method was more accurate than the FOV_WS method, and could be used for all endoscopes. We also found that the labelled FOV values of many commercial endoscopes are significantly overstated. Our study can help endoscope users understand endoscope FOV and identify a proper method for FOV measurement. This paper can be used as a reference to revise the current endoscope FOV measurement standard.

Guideline for wireless capsule endoscopy in children and adolescents: A consensus document by the SEGHNP (Spanish Society for Pediatric Gastroenterology, Hepatology, and Nutrition) and the SEPD (Spanish Society for Digestive Diseases)

INTRODUCTION

Capsule Endoscopy (CE) in children has limitations based mainly on age. The objective of this consensus was reviewing the scientific evidence.

MATERIAL AND METHODS

Some experts from the Spanish Society of Gastroenterology (SEPD) and Spanish Society for Pediatric Gastroenterology, Hepatology, and Nutrition (SEGHNP) were invited to answer different issues about CE in children. These sections were: a) Indications, contraindications and limitations; b) efficacy of CE in different clinical scenarios; c) CE performance; d) CE-related complications; e) Patency Capsule; and f) colon capsule endoscopy. They reviewed relevant questions on each topic.

RESULTS

The main indication is Crohn's disease (CD). There is no contraindication for the age and in the event that the patient not to swallow it, it should be administered under deep sedation with endoscopy and specific device. The CE is useful in CD, for the management of OGIB in children and in Peutz-Jeghers syndrome (in this indication has the most effectiveness). The main complication is retention, which should be specially taken into account in cases of CD already diagnosed with malnutrition. A preparation regimen based on a low volume of polyethylene glycol (PEG) the day before plus simethicone on the same day is the best one in terms of cleanliness although does not improve the results of the CE procedure.

CONCLUSIONS

CE is safe and useful in children. Indications are similar to those of adults, the main one is CD to establish both a diagnosis and disease extension. Moreover, only few limitations are detected in children.

Recommendations to quantify villous atrophy in video capsule endoscopy images of celiac disease patients

AIM

To quantify the presence of villous atrophy in endoscopic images for improved automation.

METHODS

There are two main categories of quantitative descriptors helpful to detect villous atrophy: (1) Statistical and (2) Syntactic. Statistical descriptors measure the small intestinal substrate in endoscope-acquired images based on mathematical methods. Texture is the most commonly used statistical descriptor to quantify villous atrophy. Syntactic descriptors comprise a syntax, or set of rules, for analyzing and parsing the substrate into a set of objects with boundaries. The syntax is designed to identify and distinguish three-dimensional structures based on their shape.

RESULTS

The variance texture statistical descriptor is useful to describe the average variability in image gray level representing villous atrophy, but does not determine the range in variability and the spatial relationships between regions. Improved textural descriptors will incorporate these factors, so that areas with variability gradients and regions that are orientation dependent can be distinguished. The protrusion syntactic descriptor is useful to detect three-dimensional architectural components, but is limited to identifying objects of a certain shape. Improvement in this descriptor will require incorporating flexibility to the prototypical template, so that protrusions of any shape can be detected, measured, and distinguished.

CONCLUSION

Improved quantitative descriptors of villous atrophy are being developed, which will be useful in detecting subtle, varying patterns of villous atrophy in the small intestinal mucosa of suspected and known celiac disease patients.

Inflammatory bowel disease in India - Past, present and future

There is rising incidence and prevalence of inflammatory bowel disease (IBD) in India topping the Southeast Asian (SEA) countries. The common genes implicated in disease pathogenesis in the West are not causal in Indian patients and the role of "hygiene hypothesis" is unclear. There appears to be a North-South divide with more ulcerative colitis (UC) in north and Crohn's disease (CD) in south India. IBD in second generation Indian migrants to the West takes the early onset and more severe form of the West whereas it retains the nature of its country of origin in migrants to SEA countries. The clinical presentation is much like other SEA countries (similar age and sex profile, low positive family history and effect of smoking, roughly similar disease location, use of aminosalicylates for CD, low use of biologics and similar surgical rates) with some differences (higher incidence of inflammatory CD, lower perianal disease, higher use of aminosalicylates and azathioprine and lower current use of corticosteroids). UC presents more with extensive disease not paralleled in severity clinically or histologically, follows benign course with easy medical control and low incidence of fulminant disease, cancer, complications, and surgery. UC related colorectal cancer develop in an unpredictable manner with respect to disease duration and site questioning the validity of strict screening protocol. About a third of CD patients get antituberculosis drugs and a significant number presents with small intestinal bleed which is predominantly afflicted by aggressive inflammation. Biomarkers have inadequate diagnostic sensitivity and specificity for both. Pediatric IBD tends to be more severe than adult. Population based studies are needed to address the lacunae in epidemiology and definition of etiological factors. Newer biomarkers and advanced diagnostic techniques (in the field of gastrointestinal endoscopy, molecular pathology and genetics) needs to be developed for proper disease definition and treatment.

Current role of capsule endoscopy in Crohn’s disease

Capsule endoscopy (CE) currently plays an important role in Crohn’s disease (CD). It is a noninvasive technique that has led to a breakthrough in the endoscopic diagnosis of diseases of the small intestine. Its superior diagnostic performance and excellent safety profile lead to its considerable acceptance on the part of the patient. This paper reviews current indications of CE in three stages of clinical practice: Suspected CD, unclassified colitis and its extensive role in diagnosed CD. The diagnostic and therapeutic impact of the results of CE on the monitoring of this disease is also reviewed. Knowledge of its applications, the interpretation of its results in an appropriate context and the existence of a validated endoscopic activity index could change the way in which these patients are managed. The definition of mucosal healing and postoperative recurrence by means of endoscopic scoring systems will endow CE with new applications in the management of CD in the near future.

Enteroscopy and radiology for the management of celiac disease complications: Time for a pragmatic roadmap

Celiac disease is the most common autoimmune enteropathy in Western countries, and is usually associated with a good response to the gluten free diet and an excellent prognosis. However, a minority of patients develop complications of the disease, such as refractory celiac disease, ulcerative jejunoileitis and neoplastic complications such as adenocarcinoma of the small bowel and enteropathy associated T cell lymphoma. Neoplastic complications described in association with celiac disease have a high mortality rate, due to their aggressive behavior and to the usual advanced stage at the time of diagnosis. In recent years, the detection of small bowel lesions has dramatically improved thank to the availability of highly performing radiologic and endoscopic techniques. The diagnostic delay of malignant complications in patients with celiac disease may be improved by establishing a pragmatic flowchart for the identification and follow up of "at risk" patients. We performed a comprehensive review of the articles published on this issue in order to promote a roadmap to be applied when facing with celiac patients with suspected small bowel complications.

Factors predicting a positive capsule endoscopy in past overt obscure gastrointestinal bleeding: a multicenter retrospective study

OBJECTIVES

Capsule endoscopy (CE) remains the examination of choice for the investigation of obscure gastrointestinal bleeding. Although the factors predicting positive CE findings in the overall obscure gastrointestinal bleeding have been investigated, the clinical characteristics that predict a positive CE in patients with past overt obscure gastrointestinal bleeding (OOGIB) have not been systematically studied.

METHODS

Between September 2004 and December 2013, 262 patients underwent CE for evaluation of past OOGIB after negative upper and lower endoscopy, and other diagnostic modalities. Patients' records were retrospectively reviewed to assess the factors that could possibly predict positive CE findings.

RESULTS

Two hundred and twenty four patients with a median age of 70 years (range: 17-87) were enrolled in the final analysis and were divided into two groups; those who had positive (group A: 118 patients) and those who had negative CE findings (group B: 106 patients). The overall diagnostic yield of CE was 52.68 %. Multivariate analysis demonstrated that age >65 years, anticoagulant use, antiplatelet use, and non-steroidal anti-inflammatory drugs use were independent predictive factors for positive findings on CE. Of the 118 patients with positive CE, therapeutic interventions were performed in 56 patients (47.46 %). Recurrence of bleeding presented in nine patients of group B compared with 39 patients of group A (p <0.001).

CONCLUSIONS

Certain clinical characteristics predict a positive CE in patients with past OOGIB. Patients with OOGIB and negative CE had a considerably lower rebleeding rate, and further invasive investigational procedures may be adjourned or may not be required, though such recommendation warrants further validation. Hippokratia 2016, 20(2): 127-132.

Capsule endoscopy: The road ahead

Since its introduction into clinical practice 15 years ago, capsule endoscopy (CE) has become the first-line investigation procedure in some small bowel pathologies, and more recently, dedicated esophageal and colon CE have expanded the fields of application to include the upper and lower gastrointestinal disorders. During this time, CE has become increasingly popular among gastroenterologists, with more than 2 million capsule examinations performed worldwide, and nearly 3000 PubMed-listed studies on its different aspects published. This huge interest in CE may be explained by its non-invasive nature, patient comfort, safety, and access to anatomical regions unattainable via conventional endoscopy. However, CE has several limitations which impede its wider clinical applications, including the lack of therapeutic capabilities, inability to obtain biopsies and control its locomotion. Several research groups are currently working to overcome these limitations, while novel devices able to control capsule movement, obtain high quality images, insufflate the gut lumen, perform chromoendoscopy, biopsy of suspect lesions, or even deliver targeted drugs directly to specific sites are under development. Overlooking current limitations, especially as some of them have already been successfully surmounted, and based on the tremendous progress in technology, it is expected that, by the end of next 15 years, CE able to perform both diagnostic and therapeutic procedures will remain the major form of digestive endoscopy. This review summarizes the literature that prognosticates about the future developments of CE.

Clinical Experience with the PillCam Patency Capsule prior to Video Capsule Endoscopy: A Real-World Experience

Background. In patients with known or suspected risk factors for gastrointestinal stenosis, the PillCam patency capsule (PC) is given before a video capsule endoscopy (VCE) in order to minimize the risk of capsule retention (CR). CR is considered unlikely upon excretion of the PC within 30 hours, excretion in an undamaged state after 30 hours, or radiological projection to the colon. Methods. We performed a retrospective analysis of 38 patients with risk factors for CR, who received a PC from 02/2013 to 04/2015 at Klinikum Augsburg. Results. Sixteen of our 38 patients observed a natural excretion after a mean time of 34 hours past ingestion. However, only 8 patients observed excretion within 30 hours, as recommended by the company. In 20 patients passage of the PC into the colon was shown via RFID-scan or radiological imaging (after 33 and 45 hours, resp.). Only 2 patients showed a pathologic PC result. In consequence, 32 patients received the VCE; no CR was observed. Conclusion. Our data indicates that a VCE could safely be performed even if the PC excretion time is longer than 30 hours and the excreted PC was not screened for damage.

Degree of concordance between single balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding after an initial positive capsule endoscopy finding

INTRODUCTION

In patients with obscure gastrointestinal bleeding (OBGIB) capsule endoscopy (CE) is the initial diagnostic procedure of choice. Often patients undergo single balloon enteroscopy (SBE) with both diagnostic and therapeutic intention after CE. Although SBE offers a therapeutic benefit, long procedure times, complexity, and invasiveness are drawbacks. We aimed to evaluate the diagnostic correlation between these two modalities after an initial positive CE finding.

METHODS

We performed a retrospective review of 418 patients who underwent CE at our institution from January 2010 to May 2014. A total of 95 patients were analyzed after selecting patients that underwent SBE originally after a positive CE result for the evaluation for OGIB. Agreement beyond chance was evaluated using the κ coefficient. A p value less than 5% was considered statistically significant.

RESULTS

The mean age of our population was 65.8 ± 12.2 and it was female predominant: 57/95 (60%). The most frequent positive findings were vascular lesions found on SBE in 31.6% and on CE in 41.1%. There was a strong agreement when identifying active bleeding and clots [κ=0.97; 95% confidence interval (CI) 0.92-1.03; p ⩽ 0.0001], and a moderate agreement when diagnosing vascular lesions (0.41; 95% CI 0.21-0.61; p ⩽ 0.0001). There was fair agreement for ulcers (0.26; 95% CI 0.07-0.59; p = 0.005). There was a low correlation between masses, polyps, and others.

CONCLUSION

CE still remains the initial test of choice in evaluating stable patients with OBGIB since it has strong-to-fair concordance for the major small bowel findings. However, in cases of severe overt small bowel bleeding, balloon-assisted enteroscopy can be considered the initial procedure of choice since it is therapeutic as well as diagnostic and this approach avoids delays in treatment. Further research should focus on methods to improve interpretation of CE and enhance the ability to evaluate the entire small bowel with SBE.

Capsule Studies Performed in a Tertiary Care Center Versus Community Referrals Prior to Single-Balloon Enteroscopy: Does It Matter?

BACKGROUND AND AIMS

Within the community, patients with positive capsule endoscopy (CE) are often referred to centers performing balloon-assisted enteroscopy. There is limited data evaluating the concordance and diagnostic/therapeutic yield of CE performed in the community versus CE conducted at institutions experienced with enteroscopy. The primary aim of this retrospective study was to evaluate the concordance between CE and SBE after CE was performed either in the community or at our tertiary care center.

METHODS

A total of 141 patients were analyzed after selecting patients undergoing evaluation of obscure GI bleeding from January 2010 to May 2014. Forty-seven CE were performed inside and the remaining 94 CE were performed at outside institutions prior to single-balloon enteroscopy at our institution. Agreement beyond chance was evaluated using kappa coefficient. A p value <5% was considered significant.

RESULTS

The most frequent findings on CE were vascular lesions in 39 patients (41.5%) within the referral group and 23 within inside patients (48.9%), followed by active bleeding/clots in 23 patients (24.5%) and in 14 patients (29.8%) respectively. There was a fair degree of concordance in the referral group for vascular lesions 0.23 (0.03-0.42) compared to a good degree in the inside group 0.65 (0.44-0.87). Fair agreement was found looking at ulcers within the referral group 0.29 (0.06-0.65) compared to a moderate agreement in the inside group 0.55 (0.17-0.94).

CONCLUSIONS

Degree of concordance for vascular lesions and ulcers was significantly higher for patients undergoing CE at our institution compared to those referred from the community. Patients referred to tertiary care centers for balloon-assisted enteroscopy may benefit from advanced endoscopists re-reading the capsule findings or even potentially repeating CE in hemodynamically stable patients if the study is not available.

Hookworm infestation is not an uncommon cause of obscure occult and overt gastrointestinal bleeding in an endemic area: A study using capsule endoscopy

Obscure gastrointestinal bleeding (OGIB), particularly occult, has been reported to be caused by hookworm infestation rarely from tropical countries, particularly India. Hence, we undertook a retrospective study evaluating frequency, clinical spectrum, and outcome of patients with OGIB associated with worm infestation. Data of consecutive patients with OGIB undergoing capsule endoscopy in a multilevel university hospital in northern India were retrospectively analyzed. Twenty-one out of 163 (13 %) patients with OGIB had hookworm infestation detected on capsule endoscopy. Of 21 patients (median age 65 years [range 19-82], 17 [81 %] male), 16 had overt and 5 had occult OGIB. Another lesion that could explain OGIB was present in 8/21 patients, 3/5 with OGIB occult, and 5/16 overt (p = ns). All the patients received treatment with albendazole and appropriate measures for the associated lesion, if any. Patients with hookworm infestation with another lesion experienced recurrent bleeding more often than those with worm infestation only. Hookworm infestation is an important cause of occult as well as overt OGIB and may be present even in association with another lesion. Those with additional lesion had recurrent bleeding more often than those with worm infestation alone.

Deep enteroscopy with a conventional colonoscope: initial multicenter study by using a through-the-scope balloon catheter system

BACKGROUND AND AIMS

The advent of capsule endoscopy has revolutionized evaluation of the small bowel. Capsule endoscopy has become the criterion standard as the initial examination to diagnose small-bowel abnormalities, but does not allow for tissue sampling or therapeutic intervention. Deep enteroscopy can be performed by using a balloon-assisted device or a spiral overtube for both diagnostic and therapeutic interventions of the small bowel. Deep enteroscopy is time-consuming and requires special endoscopes and accessories to perform the examination. We studied a novel through-the-scope balloon catheter system used for deep enteroscopy that uses a conventional colonoscope and standard accessories.

METHODS

We performed a 9-center, retrospective study using a novel TTS balloon system for small-bowel evaluation. The new through-the-scope device is an on-demand balloon catheter that is inserted through the instrument channel of a standard colonoscope and enables deep advancement into the small bowel in either the anterograde or retrograde approach. It consists of a balloon inflation/deflation system and a single-use balloon catheter designed for anchoring in the small bowel. The balloon is inflated to an anchoring pressure in the small intestine, and a repetitive push-pull technique is performed, with the endoscope sliding over the guiding catheter to the inflated balloon. The catheter may be removed and reinserted to allow for therapeutic intervention while maintaining the endoscope position.

RESULTS

A total of 98 patients were included; 52% were male, and the mean age was 55 years old (range 15-94 years). Indications included abdominal pain, iron-deficiency anemia, occult GI bleeding, diarrhea, abnormal capsule endoscopy, weight loss, protein losing enteropathy, retained foreign body, altered anatomy ERCP, and small-bowel strictures. Anterograde enteroscopy was performed in 65 patients. The average depth of insertion was 158 cm (range 50-350 cm) from the pylorus. Retrograde enteroscopy was performed in 33 cases. The average depth of insertion was 89 cm (range 20-150 cm) beyond the ileocecal valve. Overall, diagnostic yield was 44%. The average advancement time for the anterograde and retrograde enteroscopy cases was 15.5 minutes. There were no procedural adverse outcomes reported in the 98 cases.

CONCLUSIONS

The TTS advancing balloon is a safe and effective way to perform deep enteroscopy by using a conventional colonoscope without the need for an overtube. Procedure time is shorter than that of other forms of deep enteroscopy. Diagnostic yield and depth of insertion are on par with other forms of deep enteroscopy. This is the largest reported study using this novel technology to diagnose and treat small-bowel disease.