Symptomatic Patency Capsule Retention in Suspected Crohn's Disease

Retention of small bowel capsule endoscopy

PURPOSE OF REVIEW

Capsule endoscopy is widely recognized as a safe and effective procedure to evaluate the small bowel and/or the colon noninvasively. Although infrequent, capsule retention is the most feared adverse event related to this technique. A better knowledge of risk factors, improvement of patients' selection and precapsule patency assessment may further contribute to reducing the incidence of capsule retention, even in patients at increased risk for this complication.

RECENT FINDINGS

This review addresses the main risk factors for capsule retention, strategies for risk reduction such as patients' selection, dedicated cross-sectional imaging and rational use of the patency capsule, as well as management options and outcomes in the case of capsule retention.

SUMMARY

Capsule retention is infrequent, and it is usually manageable conservatively with favorable clinical outcomes. Patency capsules and dedicated small-bowel cross-sectional techniques such as CT or MR enterography should be used selectively and are both effective in decreasing the rate of capsule retention. However, none of them can completely eliminate the risk of retention.

Small bowel obstruction: what a gastroenterologist needs to know

PURPOSE OF REVIEW

Intrabdominal adhesions and intestinal hernias are the commonest cause of small bowel obstruction. Small bowel diseases, which cause small bowel obstruction, are rarer and often poses a challenge to gastroenterologists to diagnose and treat. In this review, small bowel diseases, which predispose to small bowel obstruction, are focused on, and their challenges in diagnosis and treatment.

RECENT FINDINGS

Diagnosis of causes of partial small bowel obstruction is improved with computed tomography (CT) and magnetic resonance (MR) enterography. In fibrostenotic Crohn's strictures and NSAID diaphragm disease, endoscopic balloon dilatation can delay the need for surgery if the lesion is short and accessible; however, many may still inevitably require surgery. Biologic therapy may reduce the need for surgery in symptomatic small bowel Crohn's disease wherein the strictures are predominantly inflammatory. In chronic radiation enteropathy, only refractory small bowel obstruction and those with nutritional difficulties warrant surgery.

SUMMARY

Small bowel diseases causing bowel obstruction are often challenging to diagnose and require numerous investigations over a period of time, which often culminate with surgery. Use of biologics and endoscopic balloon dilatation can help to delay and prevent surgery in some instances.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

Indications and Limitations Associated with the Patency Capsule Prior to Capsule Endoscopy

The retention of the capsule used during small bowel capsule endoscopy (SBCE) is a serious complication that can occur in patients with known or suspected small bowel stenosis, and a prior evaluation of the patency of the gastrointestinal (GI) tract is therefore essential. Patency capsule (PC) is a non-diagnostic capsule the same size as the diagnostic SBCE. To date, there are no clear guidelines regarding the contraindications for undergoing a PC evaluation prior to SBCE. Each small bowel disorder has specific occasions to inhibit the progress of PC and SBCE, even though they do not have any stenotic symptoms or abnormalities on imaging. In this review, we summarize the indications and limitations of PC prior to SBCE, especially the contraindications, and discuss clinical scenarios in which even PC should be avoided, and therefore such areas of stenosis should be evaluated by alternative modalities. We thus propose this new algorithm to evaluate the patency of the GI tract for patients with suspected and known small bowel stenosis in order that they may undergo SBCE safely.

Endoscopic Evaluation and Therapeutic Considerations of Small Bowel Crohn’s Disease

Small bowel evaluation is warranted in all newly diagnosed cases of Crohn’s disease (CD) as small bowel is involved in two-thirds of CD patients at diagnosis and the involvement can be discontinuous. Endoscopic evaluation of the small bowel in suspected or established CD can be done by video capsule endoscopy (VCE), device assisted enteroscopy (DAE) (which includes single and double balloon enteroscopy, novel motorized spiral enteroscopy (NMSE) and balloon guided endoscopy (BGE)) and intra-operative enteroscopy (IOE). In suspected CD with a negative ileo-colonoscopy, VCE is the preferred initial diagnostic modality in the absence of obstructive symptoms or known stenosis. VCE should be preceded by cross-sectional imaging or patency capsule testing if obstruction is suspected given with high retention risk. In established cases, small bowel cross-sectional imaging (magnetic resonance or computed tomography enterography) is preferred over VCE as it can assess transmural and extra-luminal involvement. VCE is indicated subsequently if necessary to assess disease extent, unexplained symptoms (e.g., anemia, malnutrition) or mucosal healing. Pan-enteric capsule endoscopy (PCE) and the use of artificial intelligence are the recent developments with VCE. DAE with small bowel biopsy can provide definitive evidence of CD including the extent and severity. A final diagnosis of CD is based on the constellation of clinical, radiologic, histologic and endoscopic features. Newer technologies like NMSE and BGE can help with deeper and faster small bowel evaluation. DAE has also allowed endoscopic treatment of small bowel strictures, small bowel bleeding and retrieval of retained capsule or foreign bodies. Endoscopic balloon dilation (EBD), endoscopic electro-incision, strictureplasty and stenting have shown promising results in CD related small bowel strictures. In conclusion, endoscopic evaluation of the small bowel is rapidly evolving field that has a major role in diagnosis and management of small bowel CD and can alter treatment outcomes in properly selected patients.

Evaluation of Small-Bowel Patency in Crohn's Disease: Prospective Study with a Patency Capsule and Computed Tomography

Background and Purpose

Patency capsule (PC) examination is usually performed - previously to capsule endoscopy - to evaluate small-bowel patency in patients with established Crohn's disease (CD). The reported PC retention rate is significantly higher than expected. Our aims were to assess small-bowel patency, to determine the precise location of the retained PC in patients with CD, and to determine the false positive rate of evaluation with a radiofrequency identification tag (RFIT) scanner.

Methods

This is a prospective single-center study including CD patients with clinical indication for small-bowel capsule endoscopy. PillCam® PC examination was performed on all patients to assess small-bowel patency. On all patients with a positive identification of the PC using an RFIT scanner, 30 h after ingestion, an abdominal CT was performed in order to identify its precise location.

Results

Fifty-four patients were included. The PC retention rate, according to evaluation with the RFIT scanner, was 20% (in 11 patients) 30 h after ingestion. These patients were then submitted to abdominal CT, which revealed that there was small-bowel retention in 5 cases (9%). Higher CRP levels, penetrating disease, and a history of abdominal surgery were associated with an increased risk of PC retention (p = 0.007, p = 0.011, and p = 0.033, respectively). On multivariate analysis, there was an independent association between small-bowel PC retention and CRP levels >5 mg/dL (OR = 15.5; p = 0.03).

Discussion

The small-bowel PC retention rate (9%) was considerably lower than those found in previous reports. Our results show that, with this protocol, the false-positive cases of RFIT scans or plain abdominal X-rays may be avoided. This may contribute to more extensive application of capsule endoscopy without the risk of small-bowel retention.

Successful medical treatment for a Crohn's disease patient with a perforation by a second-generation patency capsule

Background and study aims  Symptomatic capsule retention is a very rare adverse event following patency capsule, and the vast majority of cases are resolved without either surgical or endoscopic intervention. We herein describe a rare case of small bowel perforation after swallowing a patency capsule in a 37-year-old man suspected of having Crohn's disease.

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.

Acute Small Bowel Perforation Caused by Obstruction of a Novel Tag-Less AgileTM Patency Capsule

A 74-year-old man visited our hospital complaining of abdominal pain. An abdominal computed tomography scan showed multiple wall thickness of the small bowel. Capsule endoscopy was recommended for further evaluation, and patency capsule examination was performed. Eighteen hours after patency capsule ingestion, he experienced small bowel perforation with severe peritonitis caused by intestinal pressure rising because of the patency capsule trapped in his terminal ileum. An ileocolic resection was performed, including the removal of the sclerotic ileum as an emergency surgery. A pathological examination showed transmural inflammation and multiple ulcers with perforation of the small intestine, consistent with Crohn's disease. Here, we report a rare and valuable case of novel tag-less Agile^TM patency capsule (Given Imaging Ltd., Yoqneam, Israel) retention leading to small bowel perforation.

Diagnostic yield of capsule endoscopy versus magnetic resonance enterography and small bowel contrast ultrasound in the evaluation of small bowel Crohn's disease: Systematic review and meta-analysis

BACKGROUND AND AIMS

Capsule endoscopy (CE), magnetic resonance enterography (MRE) and small bowel (SB) intestinal contrast ultrasound (SICUS) are the modalities of choice for SB evaluation. This study aimed to compare the diagnostic yield (DY) of CE to MRE and SICUS in detection and monitoring of SB CD through meta-analysis of the available literature.

METHODS

We performed a systematic literature search for trials comparing the accuracy of CE, MRE and SICUS for detection of active SB inflammation in patients with suspected and/or established CD. Only prospective studies comparing CE with another additional diagnostic modality were included in the final analysis. Pooled odds ratios (ORs) for the DY of the three modalities were calculated.

RESULTS

A total of 112 studies were retrieved; following selection, 13 studies were eligible for analysis. The DY of CE for detection of active SB CD was similar to that of MRE (10 studies, 400 patients, OR 1.17; 95% CI 0.83-1.67) and SICUS (5 studies, 142 patients, OR 0.88; 95% CI 0.51-1.53). The outcomes were similar for the subgroups of suspected versus established CD and adult versus pediatric patients. CE was superior to MRE for proximal SB CD (7 studies, 251 patients, OR 2.79; 95% CI 1.2-6.48); the difference vs SICUS was not significant.

CONCLUSION

CE, MRE and SICUS have similar DY for detection of SB CD in both suspected and established CD. CE is superior to MRE for detection of proximal SB disease, however the risk of capsule retention should be considered.

Capsule endoscopy for the diagnosis and follow up of Crohn's disease: a comprehensive review of current status

Capsule endoscopy (CE) has revolutionized the diagnosis and monitoring of small bowel Crohn’s disease (CD). The procedure is patient friendly and noninvasive, and compared to cross-sectional imaging, CE allows a direct and detailed evaluation of the entire small bowel mucosa with a high sensitivity for the earliest lesions of CD. Today, CE is the leading modality for visualizing the small bowel in suspected CD, and validated activity indices are available for the follow up of patients with established CD. CE of the entire gastrointestinal tract (panenteric CE) was recently introduced as a new diagnostic approach in patients examined for CD, and preliminary results are promising. There are important limitations, involving mainly capsule retention. Furthermore, a diagnostic criterion for CD has never been validated, and lesions detected by CE are not specific for CD. Hence, concern has been raised about a low specificity compared to other diagnostic modalities. Important questions about the optimal bowel preparation, selection of patients for CE and the optimal reading protocol remain to be clarified. The aim of this review is to evaluate the performance of CE for diagnosing CD and assess disease activity in known CD; to compare the diagnostic accuracy of CE to that of cross-sectional imaging; to discuss limitations; and to define the place of CE in the diagnostic algorithm in suspected or known CD.