The effect of metoclopramide in capsule enteroscopy

Glucagon-like peptide-1 receptor agonists and capsule endoscopy in patients with diabetes: a matched cohort study

BACKGROUND AND AIMS

Video capsule endoscopy (VCE) is valuable for assessing conditions like GI bleeding, anemia, and inflammatory bowel disease. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are prescribed for diabetes and weight loss, with their pharmacologic effects including delayed gastric emptying. This study investigates the impact of GLP-1 RA use on VCE outcomes in patients with diabetes.

METHODS

This retrospective cohort study involves patients with diabetes undergoing VCE while on GLP-1 RAs matched in a 1:1 ratio with control subjects, who are not on GLP-1 RAs, based on demographics and diabetes-related factors. The primary outcome was gastric transit time in VCE studies, whereas secondary outcomes were incomplete small-bowel evaluation and small-bowel transit time.

RESULTS

In the GLP-1 RA cohort with 68 patients, 5 (7%) experienced failure to pass the video capsule through the stomach; all control subjects passed the video capsule successfully (P = .06). GLP-1 RA patients had a longer gastric transit time (99.3 ± 134.2 minutes) compared with control subjects (25.3 ± 31.6 minutes, P < .001). Multivariate analysis revealed GLP-1 RA use was associated with an increased gastric transit time by 74.5 minutes (95% confidence interval, 33.8-115.2; P < .001) compared with control subjects, after adjusting for relevant factors. Sixteen GLP-1 RA patients (23.5%) experienced incomplete passage of the video capsule through the small intestine, a significantly higher rate compared with 3 patients in the control group (4.4%, P < .01).

CONCLUSIONS

GLP-1 RA use is associated with a prolonged gastric transit time and a higher rate of incomplete small-bowel evaluation during VCE. Future studies may be crucial for evaluating strategies to mitigate these effects.

[Optimal Bowel Preparation for Capsule Endoscopy and Device-assisted Enteroscopy]

For improved examination of video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), bowel preparation is an essential issue. Multiple factors like air bubbles, food material in the small bowel, and gastric and small bowel transit time affect the small bowel visualization quality (SBVQ), diagnostic yield (DY) and cecal completion rate (CR). Bowel preparation with polyethylene glycol (PEG) solution enhances SBVQ and DY, but it has no effect on CR. Bowel preparation with PEG solution 2 L is similar to PEG 4 L in SBVQ, DY, and CR. Bowel preparation with fasting or PEG solution combined with anti-foaming agents like simethicone enhance SBVQ, but it has no effect on CR. Bowel preparation with prokinetics is not commonly recommended. Optimal timing for purgative bowel preparation has yet to be established. However, the studies regarding bowel preparation for DAE are not sufficient. European Society of Gastrointestinal Endoscopy (ESGE) recommends 8-12 hours fasting from solid food and 4-6 hours fasting from liquids prior to the antegrade DAE. For retrograde DAE, colonoscopy preparation regimen is recommended. This article reviews the literature and ESGE, 2013 Korean published guidelines regarding bowel preparation for VCE and DAE, following suggestion for optimal bowel preparation for VCE and balloon enteroscopy.

Preparation, Timing, Prokinetics, and Surface Agents in Video Capsule Endoscopy

There is a trend in data to support active preparation for video capsule endoscopy (VCE), but the timing of this remains unclear. Split dosing may be the most efficacious preparation. Study methodology continues to evolve, with increased use of standardized scales, with the addition of diagnostic yield as an outcome. The use of adjuncts has not been detrimental, but their value has not been proved to improve outcomes of VCE.

Effectiveness of Improved Use of Chewing Gum During Capsule Endoscopy in Decreasing Gastric Transit Time: A Prospective Randomized Controlled Study

Background/Aim: Chewing gum throughout small bowel capsule endoscopy (SBCE) increases completion rates (CRs) but decreases small bowel transit time (SBTT) and diagnostic yield (DY). We determined the effects of chewing gum early during SBCE on gastric transit time (GTT), SBTT, CR, DY, and gastroscopy intervention. Methods: We prospectively enrolled patients (ages 16-80 years) undergoing SBCE between January and June 2019. Patients were randomized to a chewing gum group (103 patients) and a control group (102 patients). Patients in the former group chewed one piece of gum for ~15 min every 30 min during the first hour of SBCE. Two gastroenterologists blinded to the study group examined the data. Results: GTT was shorter in the chewing gum group (19.0 min, interquartile range: 17.0-52.0 min) than in the control group [42.5 min (23.25-60 min); P = 0.01]. SBTT was similar in the two groups [318.5 min (239.5-421.3 min) vs. 287.0 min (216.0-386.0 min); P = 0.08]. Gastroscopy rate was lower in the chewing gum group (15.53 vs. 32.35%, P = 0.005). CR (95.15 vs. 89.22%, P = 0.114) and DY (66.02 vs. 59.80%, P = 0.359) did not differ between the groups. The number of abnormal-lesion types detected per patient was higher in the chewing gum group [1.0 (0.0-2.0) vs. 2.0 (0.0-2.0); P = 0.049]. Conclusions: Chewing gum early during SBCE significantly reduced GTT and gastroscopy intervention, with no influence on SBTT (Trial number: NCT03815136).

Adverse events of video capsule endoscopy over the past two decades: a systematic review and proportion meta-analysis

BACKGROUND

A full spectrum of video capsule endoscopy (VCE) adverse events over the past two decades has not been evaluated. We aimed to determine pooled rates, predictors and temporal-trend of VCE adverse events over the past two decades.

METHODS

Systematic search of PubMed and EMBASE for English-language publications reporting VCE adverse events (January 1, 2000 to March 31, 2019). Data were extracted independently by two investigators. Pooled VCE adverse event rates were calculated using the random or fixed model as appropriate. Predictors and temporal-trend of each adverse event were performed by meta-regression analyses.

RESULTS

In total, 402 studies were identified, including 108,079 VCE procedures. Rate of retention, swallow disorder, aspiration, technical failure, and procedural adverse events were 0.73% (95% confidence interval [CI] 0.59-0.89%), 0.75% (95% CI 0.43-1.13%), 0.00% (95% CI 0.00-0.00%), 0.94% (95% CI 0.65-1.28%), 0.67% (95% CI 0.32-1.10%), respectively; incomplete examination rate of esophagus, stomach, small bowel, and colon were 9.05%, 7.69%, 12.08%, 19.19%, respectively. Patency capsule reduced retention rate by 5.04%, whereas known inflammatory bowel disease increased retention rate by 4.29%. Elder was the risk and protective factor for small bowel incomplete examination (0.30%) and swallow disorder (- 0.72%), respectively. Rates of retention and small bowel incomplete examination significantly declined over time (P = .0006 and P < .0001)..

CONCLUSIONS

VCE adverse event rates were generally low, and retention and small bowel incomplete examination rates declined over the past two decades. Patients with known inflammatory bowel disease or elder should be alerted to high risk of retention or small bowel incomplete examination (PROSPERO: CRD42019139595).

Capsule endoscopy for small-intestinal disorders: Current status

Small-bowel capsule endoscopy (SBCE) is used widely because of its non-invasive and patient-friendly nature. SBCE can visualize entire small-intestinal mucosa and facilitate detection of small-intestinal abnormalities. In this review article, we focus on the current status of SBCE. Several platforms for SBCE are available worldwide. Third-generation SBCE (PillCam^® SB3) has a high-resolution camera equipped with an adaptive frame rate system. Several software modes have been developed to reduce the reading time for capsule endoscopy and to minimize the possibility of missing lesions. The main complication of SBCE is capsule retention. Thus, the main contraindication for SBCE is known or suspected gastrointestinal obstruction unless intestinal patency is proven. Possible indications for SBCE are obscure gastrointestinal bleeding, Crohn's disease, small-intestinal polyps and tumors, and celiac disease. Colon capsule endoscopy (CCE) can observe inflamed colonic mucosa non-invasively, and allows for the continuous and non-invasive observation of the entire intestinal tract (pan-endoscopy). Recently, application of CCE as pan-enteric endoscopy for inflammatory bowel diseases (including Crohn's disease) has been reported. In the near future, reading for CE will be assisted by artificial intelligence, and reading CE videos for long periods will not be required.

Sham Feeding with Bacon Does Not Alter Transit Time or Complete Examination Rate During Small Bowel Capsule Endoscopy

BACKGROUND

During capsule endoscopy (CE) studies, the complete examination rate (CER) can be increased by prolonging capsule battery life or reducing gastric transit time (GTT) and/or small bowel transit time (SBTT). However, despite enhanced battery life, 10% of studies remain incomplete. Previously studied interventions to reduce SBTT and enhance CER have produced conflicting results. We hypothesize that this may be a consequence of an insufficiently potent stimulus of small bowel motility.

AIMS

To examine whether potent stimulation of the cephalic response of digestion during small bowel CE reduces GTT and/or SBTT and thus increases the CER.

METHODS

A single-blind randomized trial was performed to evaluate the effect of bacon sham feeding on GTT, SBTT and CER.

RESULTS

Baseline characteristics were similar between 63 sham fed patients and 59 controls. The median GTT was 17 min (9-65) in the bacon group and 25 min (14-55) in the control group. The median SBTT was 199 min (119-316) and 222 min (151-287), respectively. Cox proportional hazards model demonstrated no significant difference between groups for GTT (rate ratio 1.03, 95% CI 0.71-1.51, P = 0.87) or SBTT (rate ratio 1.02, 95% CI 0.70-1.49, P = 0.93). Although the taste of bacon was considered favorably by 72% of participants, taste did not correlate with GTT (ρ = 0.03, P = 0.83) or SBTT (ρ = - 0.115, P = 0.33). The CER was 91 and 95% in the bacon and control groups, respectively (P = 0.35).

CONCLUSION

Bacon sham feeding has no effect on GTT, SBTT or CER and cannot be recommended in clinical practice.

Quality Indicators for Small Bowel Capsule Endoscopy

Capsule endoscopy (CE) enables evaluation of the entire mucosal surface of the small bowel (SB), which is one of the most important steps for evaluating obscure gastrointestinal bleeding. Although the diagnostic yield of SB CE depends on many clinical factors, there are no reports on quality indicators. Thus, the Korean Gut Image Study Group (KGISG) publishes an article titled, “Quality Indicators for Small Bowel Capsule Endoscopy” under approval from the Korean Society of Gastrointestinal Endoscopy (KSGE). Herein, we initially identified process quality indicators, while the structural and outcome indicators are reserved until sufficient clinical data are accumulated. We believe that outcomes of SB CE can be improved by trying to meet our proposed quality indicators.

Optimal Bowel Preparation for Video Capsule Endoscopy

During video capsule endoscopy (VCE), several factors, such as air bubbles, food material in the small bowel, and delayed gastric and small bowel transit time, influence diagnostic yield, small bowel visualization quality, and cecal completion rate. Therefore, bowel preparation before VCE is as essential as bowel preparation before colonoscopy. To date, there have been many comparative studies, consensus, and guidelines regarding different kinds of bowel cleansing agents in bowel preparation for small bowel VCE. Presently, polyethylene glycol- (PEG-) based regimens are given primary recommendation. Sodium picosulphate-based regimens are secondarily recommended, as their cleansing efficacy is less than that of PEG-based regimens. Sodium phosphate as well as complementary simethicone and prokinetics use are considered. In this paper, we reviewed previous studies regarding bowel preparation for small bowel VCE and suggested optimal bowel preparation of VCE.

A Single-Center Randomized Controlled Trial Evaluating Timing of Preparation for Capsule Enteroscopy

Background/Aims

Intestinal lavage (IL) administration immediately before capsule enteroscopy (CE) is superior to lavage the day before the procedure. We aimed to determine the effect of IL timing on CE diagnostic yield.

Methods

Patients referred for CE were randomized prospectively into two equal groups according to the timing of IL with 2 L of polyethylene glycol solution. Group A and B underwent IL over 2 hours beginning 14 and 4 hours, respectively, before the scheduled CE. The primary outcome measure was preparation quality, measured with a predetermined validated grading scale.

Results

A total of 34 patients were randomized. The frequency of mucosal abnormalities (77% vs. 82%, p=not significant [NS]) and diagnostic yield (47% vs. 53%, p=NS) were similar between the two groups. Moreover, no significant association between the quality of small bowel preparation and the timing at which the purgative for IL was administered was observed (overall fluid transparency, p=0.936; overall mucosal invisibility, p=0.091).

Conclusions

Day-before IL is equivalent to same-day IL in terms of overall preparation quality, proportion of complete studies to cecum, small bowel transit time, frequency of identified mucosal abnormalities, and overall diagnostic yield.

Capsule endoscopy: Present status and future expectation

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

The effect of chewing gum on small-bowel transit time in capsule endoscopy: a prospective, randomized trial

BACKGROUND

Approximately 1 in 6 capsule endoscopies (CEs) does not visualize the entire small bowel at completion of the examination because of limited battery life.

OBJECTIVE

To determine whether chewing gum can reduce the small-bowel transit time and increase CE completion rates.

DESIGN

Prospective, single-blind, randomized, controlled trial.

SETTING

A tertiary university-affiliated hospital.

PATIENTS

Consecutive patients 19 years of age and older undergoing outpatient small-bowel CE from October 2010 to July 2012 were assessed for eligibility. Those with previous gastric or small-bowel surgery or ileostomy, dysphagia prohibiting capsule ingestion, diabetes mellitus with evidence of end-organ damage, use of narcotics or prokinetics within 5 days before the procedure, clinical hyper-/hypothyroidism, and symptoms suggestive of acute bowel obstruction were excluded.

INTERVENTION

Gum chewing for at least 20 minutes every 2 hours starting at the time of capsule ingestion.

MAIN OUTCOME MEASUREMENTS

Small-bowel transit time, gastric transit time, and completion rate were measured.

RESULTS

Chewing gum did not have any significant effect on gastric transit time (rate ratio 1.06; 95% CI, 0.73-1.55; P = .75), small-bowel transit time (rate ratio 0.91; 95% CI, 0.62-1.35; P = .65), or completion rate (91.67% chewing gum vs 88.71% control, P = .58) of CE.

LIMITATION

Single-center study involving relatively healthy subjects. Procedures were done on an outpatient basis so participants were not monitored for adherence to protocol.

CONCLUSIONS

Chewing gum does not speed up capsule transit or increase completion rate of CE in patients without risk factors for incomplete studies. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01241825.).

Do prokinetics influence the completion rate in small-bowel capsule endoscopy? A systematic review and meta-analysis

BACKGROUND

The use of purging for bowel cleansing prior to small-bowel capsule endoscopy (SBCE) has now been established in clinical practice. Despite that, the number of incomplete SBCEs is still around 15-20%. To date, the use of prokinetics in SBCE - aiming to improve completion rate (CR) - remains a contentious issue resulting in lack of consensus among capsule experts.

METHODS

Extensive medical literature searches were conducted (to November 2012), using suitable MeSH terms and keywords, in search of studies that compared capsule ingestion with prokinetic agents vs. controls or placebo. We examined the effects of prokinetic administration on SBCE CR (primary end point), as well as on the following secondary end points: diagnostic yield (DY), gastric transit time (GTT) and small-bowel transit time (SBTT) by meta-analysis of all relevant studies.

RESULTS

A total of 17 eligible studies (14 prospective, 3 retrospective) were identified, including 1028 individuals who ingested the capsule with no prokinetic vs. 876 who received a prokinetic. Overall, there was a higher CR in patients who ingested the capsule with prokinetics vs. controls (OR [95% CI]: 1.96 [1.38-2.78]). Of the two most readily available prokinetics, metoclopramide was associated with superior SBCE CR vs. control (OR [95% CI]: 2.8 [1.35-3.21]), while erythromycin showed no benefit (OR [95% CI]: 1.36 [0.61-3.03]). Where prokinetics were used alone, neither metoclopramide nor erythromycin showed any benefit on CR. There was no benefit of prokinetics (over controls) on DY. However, metoclopramide had a significant effect on GTT and SBTT.

LIMITATIONS

The majority of the included studies were heterogeneous, and the effect of prokinetics on image quality and mucosal visualization was not examined.

CONCLUSION

Our pooled data shows that the use of prokinetics for capsule ingestion improves CR in SBCE. This effect appears to be particularly evident with metoclopramide, when used concurrently with purging and/or use of real-time monitoring. In a small number of studies, erythromycin showed - through its gastrokinetic effect - marginal benefit. No prokinetic has a beneficial effect on SBCE DY.

Guidelines for Bowel Preparation before Video Capsule Endoscopy

The preparation for video capsule endoscopy (VCE) of the bowel suggested by manufacturers of capsule endoscopy systems consists only of a clear liquid diet and an 8-hour fast. While there is evidence for a benefit from bowel preparation for VCE, so far there is no domestic consensus on the preparation regimen in Korea. Therefore, we performed this study to recommend guidelines for bowel preparation before VCE. The guidelines on VCE were developed by the Korean Gut Image Study Group, part of the Korean Society of Gastrointestinal Endoscopy. Four key questions were selected. According to our guidelines, bowel preparation with polyethylene glycol (PEG) solution enhances small bowel visualization quality (SBVQ) and diagnostic yield (DY), but it has no effect on cecal completion rate (CR). Bowel preparation with 2 L of PEG solution is similar to that with 4 L of PEG in terms of the SBVQ, DY, and CR of VCE. Bowel preparation with fasting or PEG solution combined with simethicone enhances the SBVQ, but it does not affect the CR of VCE. Bowel preparation with prokinetics does not enhance the SBVQ, DY, or CR of VCE.

Relationship between gastric transit time and complete examination rate of the capsule endoscopy examinations

AIM: To investigate the right timing for intervention when capsule endoscope transits for a relatively long time in the stomach.

METHODS: The following items were analyzed in 109 patients who underwent capsule endoscopy (CE) examinations: the relationship between gastric transit time (GTT) and complete examination rate (CER); the correlation between GTT and small bowel transit time (SBTT); the difference in GTT between groups of complete and incomplete examinations; and the risk of incomplete examination in patients with strictures of the small intestine.

RESULTS: No difference was found in CER among groups with GTT ≤ 30 min, 30-60 min, 60-90 min, or > 90 min (P = 0.971). Injection of metoclopramide in patients with longer GTT resulted in shorter SBTT compared to their counterparts with shorter GTT (t = -2.027, P = 0.046). No difference was found in GTT between groups of complete and incomplete examinations [45.6 min ± 35.8 min (n = 85) vs 42.0 min ± 36.4 min (n = 24), P = 0.665]. The risk of incomplete examination in patients with strictures of the small intestine was 6.588-fold higher than those without strictures (OR = 6.588, 95% CI = 1.866-23.258, P = 0.004).

CONCLUSION: Too early delivery of capsule endoscope in the duodenum might not improve CER. This procedure should be considered only if the retention of CE in the stomach exceeds 90 min, and it is better to be completed within 30 min.

Effects of the oral administration of mosapride citrate on capsule endoscopy completion rate

Background/Aims

In capsule endoscopy (CE), the capsule does not always reach the cecum within its battery life, which may reduce its diagnostic yield. We evaluated the effect of mosapride citrate, a 5-hydroxytryptamine-4 agonist that increases gastrointestinal motility, on CE completion.

Methods

In a retrospective study, we performed univariate and multivariate analyses for 232 CE procedures performed at our hospital. To identify factors that affect CE completion, the following data were systematically collected: gender, age, gastric transit time (GTT), nonsteroidal anti-inflammatory drug administration, previous abdominal surgery, hospitalization, use of a polyethylene glycol solution, use of mosapride citrate (10 mg), body mass index (BMI), and total recording time.

Results

The univariate analysis showed that oral mosapride citrate, GTT, and BMI were associated with improved CE completion. Multivariate analyses showed that oral mosapride citrate (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.01 to 3.91) and GTT (OR, 2.34; 95% CI, 1.13 to 4.87) were significant factors for improving the CE completion. Oral mosapride citrate significantly shortened the GTT and small bowel transit time (SBTT).

Conclusions

Oral mosapride citrate reduced the GTT and SBTT during CE and improved the CE completion rate.

New vision in video capsule endoscopy: current status and future directions

Now, more than 10 years after the approval of video capsule endoscopy (VCE), the technology has become an essential component in the management of several clinical conditions. Currently, two capsules are approved in the USA for visualizing the small bowel mucosa, one capsule is authorized for oesophageal assessment and several others are in use or under evaluation worldwide. New investigations have focused on optical improvements, advances in intestinal cleansing and risk reduction strategies to optimize VCE methodologies in clinical care. Established indications diagnosed using VCE include unexplained gastrointestinal bleeding, small bowel Crohn's disease (in adults and children >10 years old), localization of small bowel tumours and a broad range of miscellaneous abnormalities. Investigations are ongoing to determine the utility of VCE in colon cancer screening, assessment of oesophageal disorders and diagnosis of coeliac disease. Active research is in progress into ways to improve the efficacy of VCE recording interpretation, prolong imaging time and further enhance optics and imaging methods. To expand the potential utility of VCE, novel devices that can manoeuvre within or insufflate the gut lumen, tag or biopsy suspect lesions, or target drug delivery to specific sites are in development. To facilitate these advances, consortia have been organized to promote innovative VCE technologies.

Use of an external real-time image viewer coupled with prespecified actions enhanced the complete examinations for capsule endoscopy

BACKGROUND AND AIM

  The clinical utility of capsule endoscopy (CE) is often limited by incomplete small-bowel transit. The aim was to determine whether the use of an external real-time viewer could reduce delays caused by delayed gastric emptying of the capsule or delayed intestinal transit and also improve the rate of positive findings.

METHODS

  We compared the proportion of completed exams and positive results among a group of patients studied before introduction of real-time viewer and a group in which capsule transit through the esophagus, stomach, and small bowel was regularly monitored and actions (e.g. administration of water or intravenous metoclopramide) were taken if it was delayed.

RESULTS

  One hundred procedures in the viewer group and 100 control procedures in the age-matched controls were analyzed. In the viewer group, additional water intake (22 cases) and/or administration of metoclopramide (26 cases) were required. Endoscopic-assisted duodenal placement of the capsule was required in three cases. Overall one-third (n=33) of cases required viewer-prompted interventions. The completion rate (86% vs 66%, P=0.002) and the rate of positive findings (80% vs 67%, P=0.04) were significantly higher in the viewer group compared to the no viewer group.

CONCLUSIONS

  Checking the progress of the capsule with the external real-time viewer improved the diagnostic yield and completion rate of CE.

Advances in complete small-bowel examination by capsule endoscopy

Capsule endoscopy (CE) has a battery life of 8 h, during which time complete small-bowel examination can be achieved in most cases. However, in 10-30% of cases, the capsule cannot reach the ileocecal valve before the end of the life of the capsule's battery due to factors other than mechanical bowel obstruction. Incomplete examination of the entire small bowel leaves room for missing lesions. Some studies have shown that diabetes mellitus can lead to gastroparesis and increase gastric transit time (GTT), while history of abdominal surgery can increase small bowel transit time (SBTT). Therefore, these two factors can decrease the rate of complete small-bowel examination by CE. Purgative bowel cleansing can improve the detectability and image quality of CE, but has no significant impact on GTT, SBTT and CR. Prokinetic drugs, real-time CE, right lateral position, and chewing-gum are all under research for increasing CR. In future studies, emphasis should be placed in improving the diagnostic ability of CR and ensuring optimal intervention for patients with high risk factors for incomplete small-bowel examination.

Can we improve the diagnostic yield of small bowel video-capsule endoscopy?

Video-capsule endoscopy has revolutionized the examination of small bowel mucosa. However, this modality is relatively young and its diagnostic yield is low. Herein, we discuss different approaches to improve examination’s diagnostic yield. There are strong data supporting some of them while there is speculation about the rest. As capsule endoscopy continues to evolve there is also a strong belief that technology will overcome at least some of the obstacles that hamper capsule endoscopy’s diagnostic yield sometime in the near future.