PillCam colon capsule endoscopy versus conventional colonoscopy for the detection of severity and extent of ulcerative colitis

What Is the Optimal Bowel Preparation for Capsule Colonoscopy and Pan-intestinal Capsule Endoscopy? A Systematic Review and Meta-Analysis

BACKGROUND

The rate of adequate cleansing (ACR) and complete examinations (CR) are key quality indicators in capsule colonoscopy (CC) and pan-intestinal capsule endoscopy (PCE).

AIMS

To evaluate the efficacy of bowel preparation protocols regarding ACR and CR.

METHODS

We conducted a systematic review and meta-analysis, search terms regarding colon capsule preparation, publication date from 2006/01, and date of search 2021/12, in six bibliographic databases. Multiple steps of the cleansing protocol were assessed: diet, adjunctive laxatives, purgative solution, use of prokinetic agents, and "booster". The meta-analytical frequency of ACR and CR was estimated, and subgroup analyses performed. Strategies associated with higher ACR and CR were explored using meta-analytical univariable and multivariable regression models.

RESULTS

Twenty-six observational studies and five RCTs included (n = 4072 patients). The pooled rate of ACR was 72.5% (95% C.I. 67.8-77.5%; I2 = 92.4%), and the pooled rate of CR was 83.0% (95% C.I. 78.7-87.7%; I2 = 96.5%). The highest ACR were obtained using a low-fibre diet [78.5% (95% C.I. 72.0-85.6%); I2 = 57.0%], adjunctive laxatives [74.7% (95% C.I. 69.8-80.1%); I2 = 85.3%], and split dose < 4L polyethylene glycol (PEG) as purgative [77.5% (95% C.I. 68.4-87.8%); I2 = 47.3%]. The highest CR were observed using routine prokinetics prior to capsule ingestion [84.4% (95% C.I. 79.9-89.2%); I2 = 89.8%], and sodium phosphate (NaP) as "booster" [86.2% (95% C.I. 82.3-90.2%); I2 = 86.8%]. In univariable models, adjunctive laxatives were associated with higher ACR [OR 1.81 (95% C.I. 1.13; 2.90); p = 0.014]. CR was higher with routine prokinetics [OR 1.86 (95% C.I. 1.13; 3.05); p = 0.015] and split-dose PEG purgative [OR 2.03 (95% C.I. 1.01; 4.09), p = 0.048].

CONCLUSIONS

Main quality outcomes (ACR, CR) remain suboptimal for CC and PCE. Despite considerable heterogeneity, our results support low-fibre diet, use of adjunctive sennosides, split dose < 4L PEG, and routine prokinetics, while NaP remains the most consistent option as booster.

Clinical utility of colon capsule endoscopy: a moving target?

The purpose of this article is to provide an overview of white light colon capsule endoscopy's current clinical application, concentrating on its most recent developments. Second-generation colon capsule endoscopy (CCE2) is approved by the FDA for use as an adjunctive test in patients with incomplete colonoscopy and within Europe in patients at average risk, those with incomplete colonoscopies or those unwilling to undergo conventional colonoscopies. Since the publication of European Society of GI Endoscopy guidelines on the use of CCE, there has been a significant increase in comparative studies on the diagnostic yield of CCE. This paper discusses CCE2 in further detail. It explains newly developed colon capsule system and the current status on the use of CCE, it also provides a comprehensive summary of systematic reviews on the implementation of CCE in colorectal cancer screening from a methodological perspective. Patients with ulcerative colitis can benefit from CCE2 in terms of assessing mucosal inflammation. As part of this review, performance of CCE2 for assessing disease severity in ulcerative colitis is compared with colonoscopy. Finally, an assessment if CCE can become a cost-effective clinical service overall.

The diagnostic yield of pan-enteric capsule endoscopy in inflammatory bowel disease: A systematic review and meta-analysis

BACKGROUND AND AIM

Capsule endoscopy (CE) is a non-invasive diagnostic modality enabling real time video imaging of the gastrointestinal (GI) mucosa. Pan-enteric capsule endoscopy (PCE) is now able to thoroughly assess the entire GI tract, including for inflammatory bowel disease (IBD). Our aim was to evaluate the diagnostic accuracy of PCEs in IBD.

METHODS

We comprehensively searched electronic databases (MEDLINE, SCOPUS, EMBASE, and Cochrane Central Register of Controlled Trials) for studies comparing the diagnostic accuracy of PCE with endoscopic evaluation, intestinal ultrasound or magnetic resonance enterography (MRE). Data were analyzed by calculating forest plots and the use of the I² statistic for heterogeneity.

RESULTS

Fourteen studies were identified, with seven studies evaluating PCE diagnostic yield in Crohn's disease (CD) and seven studies in ulcerative colitis (UC). In CD, there was a trend to superiority of PCE over MRE and colonoscopy with a pooled odds ratio (OR) of 1.25 (95% CI, 0.85-1.86%) for the detection of CD. This translates to an increased diagnostic yield of 5% and 7% for PCE compared with MRE and colonoscopy, respectively. PCEs had a diagnostic sensitivity for the detection of UC of 93.8% (95% CI, 87.6-97.0%) and a specificity of 69.8% (95% CI, 38.2-89.6%).

CONCLUSION

PCEs have a comparable diagnostic yield to colonoscopy and MRE in Crohn's disease. The major difficulty remains standardization of PCE scoring systems and the lack of transmural assessment. In UC, PCE has an excellent diagnostic sensitivity and positive predictive value, but there are limitations to its use including the lack of histologic assessment and poor specificity.

Deep learning and colon capsule endoscopy: automatic detection of blood and colonic mucosal lesions using a convolutional neural network

Background and study aims  Colon capsule endoscopy (CCE) is a minimally invasive alternative to conventional colonoscopy. However, CCE produces long videos, making its analysis time-consuming and prone to errors. Convolutional neural networks (CNN) are artificial intelligence (AI) algorithms with high performance levels in image analysis. We aimed to develop a deep learning model for automatic identification and differentiation of significant colonic mucosal lesions and blood in CCE images. Patients and methods  A retrospective multicenter study including 124 CCE examinations was conducted for development of a CNN model, using a database of CCE images including anonymized images of patients with normal colon mucosa, several mucosal lesions (erosions, ulcers, vascular lesions and protruding lesions) and luminal blood. For CNN development, 9005 images (3,075 normal mucosa, 3,115 blood and 2,815 mucosal lesions) were ultimately extracted. Two image datasets were created and used for CNN training and validation. Results  The mean (standard deviation) sensitivity and specificity of the CNN were 96.3 % (3.9 %) and 98.2 % (1.8 %) Mucosal lesions were detected with a sensitivity of 92.0 % and a specificity of 98.5 %. Blood was detected with a sensitivity and specificity of 97.2 % and 99.9 %, respectively. The algorithm was 99.2 % sensitive and 99.6 % specific in distinguishing blood from mucosal lesions. The CNN processed 65 frames per second. Conclusions  This is the first CNN-based algorithm to accurately detect and distinguish colonic mucosal lesions and luminal blood in CCE images. AI may improve diagnostic and time efficiency of CCE exams, thus facilitating CCE adoption to routine clinical practice.

Review: Colon Capsule Endoscopy in Inflammatory Bowel Disease

The COVID-19 pandemic has caused considerable disruption in healthcare services and has had a substantial impact on the care of patients with chronic diseases, such as inflammatory bowel disease. Endoscopy services were significantly restricted, resulting in long waiting lists. There has been a growing interest in the use of capsule endoscopy in the diagnostic pathway and management of these patients. This review explores the published literature on the role of colon capsule endoscopy in ulcerative colitis and Crohn’s disease as a method for mucosal assessment of extent, severity, and response to treatment. Colon capsule preparation regimens and scoring systems are reported. The studies indicate that, despite inherent limitations of minimally invasive capsule endoscopy, there is increasing evidence to support the use of the second-generation colon capsule in inflammatory bowel disease evaluation, providing an additional pathway to expedite investigation of appropriate patients especially during and after the pandemic.

Current status of colon capsule endoscopy

While both the annual incidence and mortality of colorectal cancer are slowly but steadily decreasing in the United States, the incidence of such malignancy is increasing in Japan. Thus, controlling colorectal cancer in Japan is a major concern. In 2006, colon capsule endoscopy was first introduced by Eliakim et al. First-generation colon capsule endoscopy had a moderate sensitivity for detecting polyps of more than 6 mm. Thus, second-generation colon capsule endoscopy was developed to achieve higher sensitivity. Colonoscopy is the gold standard tool for colorectal cancer surveillance. With an improvement in the imaging function, the performance of second-generation colon capsule endoscopy is almost as satisfactory as that of colonoscopy. Certain situations, such as incomplete colonoscopy and contraindication for use of sedation, can benefit from colon capsule endoscopy. Colon capsule endoscopy requires a more extensive bowel preparation than colonoscopy and computed tomography colonography because it requires laxatives not only for bowel cleansing but also for promoting the excretion of the capsule. Another problem with colon capsule endoscopy includes the burden of reading and interpretation and overlook of the lesions. Currently, the development of automatic diagnosis of colon capsule endoscopy using artificial intelligence is still under progress. Although the available guidelines do not support the use of colon capsule endoscopy for inflammatory bowel disease, the possible application of colon capsule endoscopy is ulcerative colitis. This review article summarizes and focuses on the current status of colon capsule endoscopy for colorectal cancer screening and the possibility for its applicability on inflammatory bowel disease.

Non-small-bowel lesions identification by capsule endoscopy: A single centre retrospective study

BACKGROUND

Capsule endoscopy has been considered the first-line approach for the investigation of obscure gastro-intestinal bleeding since its approval in 2001. Our study aims to evaluate the diagnostic yield of capsule endoscopy in the investigation of this condition. We also analyse the incidence of non-small-bowel lesions missed after conventional endoscopy and later detected by capsule endoscopy in patients with suspected obscure bleeding.

METHODS

A total of 290 patients with negative conventional endoscopy referred to our centre to undergo a capsule endoscopy examination for the investigation of obscure gastro-intestinal bleeding. We considered as non-small-bowel lesions those outside the tract between the second duodenal portion and the ileocecal valve. We also looked for actively bleeding lesions at the time of the exam.

RESULTS

Intestinal preparation was good, adequate or poor in 74.1%, 8.4%, and 17.5% of the tests, respectively. Caecum was reached in 92.4%. Capsule retention occurred in 0.7%. Mean small bowel transit time was 5hours and 13minutes. Diagnostic yield was 73.8%. An actively bleeding lesion was noticed in 39.3% of positive tests. Capsule endoscopy revealed clinically significant non-small-bowel lesions missed at gastroscopy or colonoscopy in 30.3% of patients, 43.2% of which were bleeding.

CONCLUSIONS

Capsule endoscopy has high diagnostic yield and safety in the investigation of obscure gastro-intestinal bleedings. Given the high percentage of non-small-bowel lesions detected, it may be appropriate to consider an endoscopic second look before performing a capsule endoscopy study.

The Future of Capsule Endoscopy: The Role of Artificial Intelligence and Other Technical Advancements

Capsule endoscopy has revolutionized the management of small-bowel diseases owing to its convenience and noninvasiveness. Capsule endoscopy is a common method for the evaluation of obscure gastrointestinal bleeding, Crohn’s disease, small-bowel tumors, and polyposis syndrome. However, the laborious reading process, oversight of small-bowel lesions, and lack of locomotion are major obstacles to expanding its application. Along with recent advances in artificial intelligence, several studies have reported the promising performance of convolutional neural network systems for the diagnosis of various small-bowel lesions including erosion/ulcers, angioectasias, polyps, and bleeding lesions, which have reduced the time needed for capsule endoscopy interpretation. Furthermore, colon capsule endoscopy and capsule endoscopy locomotion driven by magnetic force have been investigated for clinical application, and various capsule endoscopy prototypes for active locomotion, biopsy, or therapeutic approaches have been introduced. In this review, we will discuss the recent advancements in artificial intelligence in the field of capsule endoscopy, as well as studies on other technological improvements in capsule endoscopy.

Colon Capsule Endoscopy for Inflammatory Bowel Disease

Colon capsule endoscopy was initially introduced in 2006. Since the results of a prospective study to evaluate first-generation colon capsule endoscopy efficacy for the detection of colonic neoplasia were unsatisfactory, second-generation colon capsule endoscopy was developed and reported in 2009. In this review article, we provide an overview of the current state of colon capsule endoscopy for evaluation of inflammatory bowel disease in a clinical setting and describe our clinical experience with this technology and its application. Among the various types of inflammatory bowel diseases, ulcerative colitis is the primary target for application of colon capsule endoscopy. Nevertheless, the initial results of studies using first-generation colon capsule endoscopy to evaluate inflammation were unclear. More recently, second-generation colon capsule endoscopy has provided higher accuracy for assessment of inflammation in patients with ulcerative colitis. Colon capsule endoscopy enables noninvasive observation (with reduced volume preparation) of mucosal inflammation severity in patients with ulcerative colitis.

Miniature gastrointestinal endoscopy: Now and the future

Since its original application, gastrointestinal (GI) endoscopy has undergone many innovative transformations aimed at expanding the scope, safety, accuracy, acceptability and cost-effectiveness of this area of clinical practice. One method of achieving this has been to reduce the caliber of endoscopic devices. We propose the collective term “Miniature GI Endoscopy”. In this Opinion Review, the innovations in this field are explored and discussed. The progress and clinical use of the three main areas of miniature GI endoscopy (ultrathin endoscopy, wireless endoscopy and scanning fiber endoscopy) are described. The opportunities presented by these technologies are set out in a clinical context, as are their current limitations. Many of the positive aspects of miniature endoscopy are clear, in that smaller devices provide access to potentially all of the alimentary canal, while conferring high patient acceptability. This must be balanced with the costs of new technologies and recognition of device specific challenges. Perspectives on future application are also considered and the efforts being made to bring new innovations to a clinical platform are outlined. Current devices demonstrate that miniature GI endoscopy has a valuable place in investigation of symptoms, therapeutic intervention and screening. Newer technologies give promise that the potential for enhancing the investigation and management of GI complaints is significant.

Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia

The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge.

Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia

The Asia-Pacific Working Group on inflammatory bowel disease (IBD) was established in Cebu, Philippines, under the auspices of the Asian Pacific Association of Gastroenterology with the goal of improving IBD care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn’s and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in the conjunction with conventional treatments for ulcerative colitis (UC) and Crohn’s disease (CD) in Asia. These statements also address how pharmacogenetics influence the treatments of UC and CD and provide guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of IBD workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing and future revisions are likely as new data continue to emerge.

Evaluating mucosal healing using colon capsule endoscopy predicts outcome in patients with ulcerative colitis in clinical remission

AIM

To examine whether second generation of colon capsule endoscopy (CCE-2) is acceptable for assessing the severity of mucosal inflammation and evaluating mucosal healing using CCE-2 is able to predict outcome in ulcerative colitis (UC) patients, especially in clinical remission.

METHODS

A total of 30 consecutive UC patients in clinical remission were enrolled to undergo CCE-2. Clinical remission was defined as clinical activity index (CAI) ≤ 4 according to Rachmilewitz index. The rate of total colon observation and colon cleansing level were evaluated. Severity of mucosal inflammation in UC was assessed according to the Mayo endoscopic subscore (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS). Relapse-free survival was assessed. Acceptability of CCE-2 was assessed using a questionnaire survey.

RESULTS

The rate of total colon observation within its battery life was 93.3%. The proportion of “excellent” plus “good” cleansing level was 73.3%. The rate of mucosal healing (MES 0, 1) assessed by CCE-2 was 77.0%. The relapse-free survival rate was significantly higher in MES 0, 1 than in MES 2, 3 (P = 0.0435), and in UCEIS 0-3 than in UCEIS 4-8 (P = 0.0211), whereas there was no significant difference between CAI 0 and CAI 1-4 groups. A questionnaire survey revealed an overall acceptability of CCE.

CONCLUSION

CCE-2 is acceptable for assessing the severity of mucosal inflammation in UC patients, especially in clinical remission. Evaluating mucosal healing using CCE-2 was able to predict outcome.

Colon capsule endoscopy for inflammatory bowel disease

Colon capsule endoscopy (CCE) is designed for direct visualization of the colonic mucosa through passive propulsion. The role of CCE in the detection of colonic polyps has been extensively evaluated. As mucosal healing has emerged as a pivotal target for treatment of inflammatory bowel disease (IBD), there is increasing data to suggest that CCE can also be used in the monitoring of mucosal inflammation in patients with active IBD, particularly in ulcerative colitis (UC) and Crohn's disease (CD). Despite advantages such as its non-invasive nature, patient's comfort, safety, and access to anatomical regions not easily reached by conventional endoscopy, CE has limitations including the lack of ability to obtain biopsies or therapeutic capabilities and no control over movement. In this review, the role and diagnostic value of CCE on diagnosis and monitoring of UC and CD patients, its safety and limitations are discussed.

Recent Advance in Colon Capsule Endoscopy: What's New?

Colon capsule endoscopy (CCE) is a relatively new diagnostic procedure for patients with suspected colonic diseases. This convenient,noninvasive method enables the physician to explore the entire colon without significant discomfort to the patient. However, while CCEcan be performed painlessly without bowel air insufflation, the need for vigorous bowel preparation and other technical limitationsexist. Due to such limitations, CCE has not replaced conventional colonoscopy. In this review, we discuss historical and recentadvances in CCE including technical issues, ideal bowel preparation, indications and contraindications and highlight further technicaladvancements and clinical studies which are needed to develop CCE as a potential diagnostic tool.

Applications of Colon Capsule Endoscopy

PURPOSE OF REVIEW

This is a review of colon capsule endoscopy (CCE) with a focus on its recent developments, technological improvements, and current and potential future indications.

RECENT FINDINGS

Based on the current literature, CCE II demonstrates comparable polyp detection rates as optical colonoscopy and CT colonography, and improved cost-effectiveness. The main limitation to patient acceptance is the requirement of a rigorous bowel preparation. Preliminary studies show good correlation between CCE and optical colonoscopy for assessment of colonic disease activity in inflammatory bowel disease (IBD). CCE II is currently FDA, approved as an adjunctive test in patients with prior incomplete colonoscopy, and in the evaluation of patients with suspected lower gastrointestinal bleeding. The test is approved in Europe as one of the options for average-risk colorectal cancer screening, and high-risk screening in patients with contraindications or unwilling to undergo colonoscopy. CCE has a potential role in the evaluation and monitoring of colonic disease activity in IBD. Future technological advances should focus on minimizing bowel preparation, improvement in reading times, and development of therapeutic capabilities. • With technological improvements, the second-generation colon capsule has a significantly higher sensitivity than the first-generation capsule for detection of colon polyps. • Colon capsule endoscopy has been approved in Europe as an option for average-risk colorectal cancer screening, and high-risk screening in patients with contraindications or unwilling to undergo colonoscopy. • Colon capsule endoscopy has received FDA approval as an option for colorectal cancer screening in patients with prior incomplete colonoscopy, and in evaluation of patients with suspected lower gastrointestinal bleeding. • Colon capsule endoscopy may have a role in evaluation and monitoring of inflammatory bowel disease. • Colon capsule endoscopy currently requires a bowel preparation that is more rigorous than colonoscopy.

Colon capsule endoscopy: toward the future

Colon capsule endoscopy is a wireless and minimally invasive technique for visualization of the whole colon. With recent improvements of technical features in second-generation systems, a more important role for colon capsule endoscopy is rapidly emerging. Although several limitations and drawbacks are yet to be resolved, its usefulness as a tool for colorectal cancer screening and monitoring disease activity in inflammatory bowel diseases has become more apparent with increased use. Further investigations, including multicenter trials, are required to evaluate the substantial role of the colon capsule in managing colorectal diseases.

Extracolonic findings with the PillCam Colon: is panendoscopy with capsule endoscopy closer?

Background and study aims: Colon capsules display images from the moment they are ingested, making the study of other extracolonic areas possible. The aim of this study was to analyze the significance of these extracolonic findings. Patients and methods: In this single-center, prospective study, 165 patients underwent colon capsule endoscopy (CCE) between September 2009 and October 2012 to rule out colonic pathology. Images were recorded, without interruptions, from the moment the capsule was ingested until its battery ran out. The study was deemed complete when the capsule had traveled from the esophagus to excretion or until the hemorrhoidal plexus was observed. Results: CCE was used for colorectal cancer (CRC) screening (81.2 %), to investigate for chronic diarrhea (9.7 %) and chronic iron deficiency anemia (6.1 %), and for patients with incomplete colonoscopy (3.0 %). The capsule returned findings in the esophagus in 52.1 % of patients, in the stomach in 45.5 % of patients, and in the small bowel in 70.7 % of patients, with the findings being considered relevant in 4.9 %, 9.7 %, and 22.6 % of patients, respectively. The whole extent of the digestive tract was fully recorded in 86.1 % of patients and the Z line could be fully observed in 57.6 % of patients. There were no adverse events. Conclusions: CCE allows the recording of images from almost the whole extent of the digestive tract in most patients, enabling relevant pathologies to be identified in extracolonic areas, particularly the small bowel. Technical and procedural improvements are still necessary in order to achieve better observation of the stomach and esophagus.

Review: capsule colonoscopy-a concise clinical overview of current status

The colon capsule endoscopy (CCE) was first introduced in 2007. Currently, the main clinical indications for CCE are completion of incomplete colonoscopy, polyp detection and investigation of inflammatory bowel disease (IBD). Although conventional colonoscopy is the gold standard in bowel cancer screening, incomplete colonoscopy remains a problem as lesions are missed. CCE compares favourably to computer tomography colonography (CTC) in adenoma detection and has therefore been proposed as a method for completing colonoscopy. However the data on CCE remains sparse and current evidence does not show its superiority over CTC or conventional colonoscopy in bowel cancer screening. CCE also seems to show good correlation with conventional colonoscopy when used to evaluate IBD, but there are not many published studies at present. Other significant limitations include the need for aggressive bowel preparation and the labour-intensiveness of CCE reading. Therefore, much further software and hardware development is required to enable CCE to fulfill its potential as a minimally-invasive and reliable method of colonoscopy.

PillCam colon capsule endoscopy (PCCE) in colonic diseases

Diseases affecting the colon are common worldwide and can cause a major health problem. Colorectal cancer (CRC) as well as Inflammatory bowel diseases represent a major cause of morbidity and mortality in western countries. PillCam colon capsule endoscopy (PCCE) is a novel and promising technology that can be useful for the screening and monitoring of colonic diseases. In the recent years many articles examined the use of various versions of PCCE-the 1st and 2nd generation versus various other endoscopic or radiologic modalities both for detection of colonic polyps or cancer and in both ulcerative colitis (UC) and Crohn's disease. The aim of the current review is to provide up to date information regarding the use and usefulness of this method in these disease.

Colon Capsule Endoscopy: Where Are We and Where Are We Going

Colon capsule endoscopy (CCE) is a noninvasive technique for diagnostic imaging of the colon. It does not require air inflation or sedation and allows minimally invasive and painless colonic evaluation. The role of CCE is rapidly evolving; for example, for colorectal screening (colorectal cancer [CRC]) in average-risk patients, in patients with an incomplete colonoscopy, in patients refusing a conventional colonoscopy, and in patients with contraindications for conventional colonoscopy. In this paper, we comprehensively review the technical characteristics and procedure of CCE and compare CCE with conventional methods such as conventional colonoscopy or computed tomographic colonography. Future expansion of CCE in the area of CRC screening for the surveillance of polyps and adenomatous lesions and for assessment of inflammatory bowel disease is also discussed.

Video capsule endoscopy in inflammatory bowel disease

Video capsule endoscopy (VCE) has evolved to become an important tool for the non-invasive examination of the small bowel, which hitherto had been relatively inaccessible to direct visualisation. VCE has been shown to play a role in monitoring the activity of small bowel Crohn’s disease and can be used to assess the response to anti-inflammatory treatment in Crohn’s disease. For those patients with Crohn’s disease who have undergone an intestinal resection, VCE has been assessed as a tool to detect post-operative recurrence. VCE may also aid in the reclassification of patients with a diagnosis of Inflammatory Bowel Disease Unclassified to Crohn’s disease. The evolution of colon capsule endoscopy (CCE) has expanded the application of this technology further. The use of CCE to assess the activity of ulcerative colitis has been described. This advance in capsule technology has also fuelled interest in its potential role as a minimally invasive tool to assess the whole of GI tract opening the possibility of its use for the panenteric assessment of Crohn’s disease. VCE is a safe procedure. However, the risk of a retained capsule is higher in patients with suspected or confirmed Crohn’s disease compared with patients having VCE examination for other indications. A retained video capsule is rare after successful passage of a patency capsule which may be utilised to pre-screen patients undergoing VCE. This paper describes the use of VCE in the assessment of inflammatory bowel disease.

PillCam COLON 2© in Crohn’s disease: A new concept of pan-enteric mucosal healing assessment

AIM: To evaluate mucosal healing in patients with small bowel plus colonic Crohn’s disease (CD) with a single non-invasive examination, by using PillCam COLON 2^© (PCC2).

METHODS: Patients with non-stricturing nonpenetrating small bowel plus colonic CD in sustained corticosteroid-free remission were included. At diagnosis, patients had undergone ileocolonoscopy to identify active CD lesions, such as ulcers and erosions, and small bowel capsule endoscopy to assess the Lewis Score (LS). After ≥ 1 year of follow-up, patients underwent entire gastrointestinal tract evaluation with PCC2. The primary endpoint was assessment of CD mucosal healing, defined as no active colonic CD lesions and LS < 135.

RESULTS: Twelve patients were included (7 male; mean age: 32 years), and mean follow-up was 38 mo. The majority of patients (83.3%) received immunosuppressive therapy. Three patients (25%) achieved mucosal healing in both the small bowel and the colon, while disease activity was limited to either the small bowel or the colon in 5 patients (42%). It was possible to observe the entire gastrointestinal tract in 10 of the 12 patients (83%) who underwent PCC2.

CONCLUSION: Only three patients in sustained corticosteroid-free clinical remission achieved mucosal healing in both the small bowel and the colon, highlighting the limitations of clinical assessment when stratifying disease activity, and the need for pan-enteric endoscopy to guide therapeutic modification.

Recent trends in diagnostic techniques for inflammatory bowel disease

Although ileocolonoscopy is the gold standard for diagnosis of inflammatory bowel disease and is useful for assessing the disease severity in the colon and terminal ileum, several alternative diagnostic techniques have been developed recently. For ulcerative colitis (UC), magnification colonoscopy, endocytoscopy, and confocal laser endomicroscopy enable assessment of histological inflammation without the need for biopsy. Capsule endoscopy is useful for detection of small intestinal and colonic lesions in both female and male patients. For UC, capsule endoscopy may be useful for evaluating colonic inflammation in patients with a previous poor colonoscopy experience, while it should be used only in Crohn's disease (CD) patients with unexplained symptoms when other examinations are negative. Magnetic resonance enterography (MRE) is particularly useful for detecting transmural inflammation, stenosis, and extraintestinal lesions, including abscesses and fistulas. MRE is also useful when evaluating small and large intestinal lesions, even in cases with severe strictures in which full evaluation of the small bowel would be virtually impossible using other devices. Therefore, the appropriate diagnostic devices for detecting CD lesions in the small and large intestine should be used.

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

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

Current status of capsule endoscopy through a whole digestive tract

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

The role of capsule endoscopy in assessing mucosal inflammation in ulcerative colitis

Assessment of mucosal inflammation is important in the management of patients with ulcerative colitis (UC). Colon capsule endoscopy (CCE) has recently been shown to be effective in colorectal polyp detection. However, its role in the evaluation of mucosal inflammation in UC is unclear. This systematic review aims to clarify the state of the art with an evidence-based summary of current studies on the utility of CCE in UC. The overall results show that the accuracy of CCE for assessment of mucosal inflammation in UC appeared to be comparable with that of colonoscopy. Long-term follow-up studies with larger sample size are needed to further validate the utility of CCE in the management of UC subjects in clinical practice.

Video capsule endoscopy: Perspectives of a revolutionary technique

Video capsule endoscopy (VCE) was launched in 2000 and has revolutionized direct endoscopic imaging of the gut. VCE is now a first-line procedure for exploring the small bowel in cases of obscure digestive bleeding and is also indicated in some patients with Crohn’s disease, celiac disease, and polyposis syndrome. A video capsule has also been designed for visualizing the esophagus in order to detect Barrett’s esophagus or esophageal varices. Different capsules are now available and differ with regard to dimensions, image acquisition rate, battery life, field of view, and possible optical enhancements. More recently, the use of VCE has been extended to exploring the colon. Within the last 5 years, tremendous developments have been made toward increasing the capabilities of the colon capsule. Although colon capsule cannot be proposed as a first-line colorectal cancer screening procedure, colon capsule may be used in patients with incomplete colonoscopy or in patients who are unwilling to undergo colonoscopy. In the near future, new technological developments will improve the diagnostic yield of VCE and broaden its therapeutic capabilities.

Colon capsule endoscopy: What we know and what we would like to know

Colonoscopy is usually perceived as an invasive and potentially painful procedure, being also affected by a small, but definite, risk of major complications (cardiopulmonary complications, perforation, hemorrhage) and even mortality. To improve both acceptability and safety, PillCam Colon Capsule Endoscopy (CCE) (Given Imaging Ltd, Yoqneam, Israel) has been developed. CCE represents a non-invasive technique that is able to explore the colon without sedation and air insufflation. The Second Generation of Colon Capsule Endoscopy (PillCam Colon 2) (CCE-2) was proven to be an accurate tool to detect colonic neoplastic lesions when used in average risk individuals. To date, the evidence supports the use of CCE-2 in case of colonoscopy failure, in patients unwilling to perform colonoscopy and when colonoscopy is contraindicated. Other potential applications, such as colorectal cancer screening or diagnostic surveillance of inflammatory bowel disease need to be clarified. In this paper, the current “state of the art”, potential application of CCE and future needs are evaluated.

Capsule endoscopy in pediatrics: A 10-years journey

Video capsule endoscopy (CE) for evaluation the esophagus (ECE), small bowel (SBCE) and the colon (CCE) is particularly useful in pediatrics, because this imaging modality does not require ionizing radiation, deep sedation or general anesthesia. The risk of capsule retention appears to be dependent on indication rather than age and parallels the adult experience by indication, making SBCE a relatively safe procedure with a significant diagnostic yield. The newest indication, assessment of mucosal change, greatly enhances and expands its potential benefit. The diagnostic role of CE extends beyond the SB. The use of ECE also may enhance our knowledge of esophageal disease and assist patient care. Colon CCE is a novel minimally invasive and painless endoscopic technique allowing exploration of the colon without need for sedation, rectal intubation and gas insufflation. The limited data on ECE and CCE in pediatrics does not yet allow the same conclusions regarding efficacy; however, both appear to provide safe methods to assess and monitor mucosal change in their respective areas with little discomfort. Moreover, although experience has been limited, the patency capsule may help lessen the potential of capsule retention; and newly researched protocols for bowel cleaning may further enhance CE’s diagnostic yield. However, further research is needed to optimize the use of the various CE procedures in pediatric populations.

Colon capsule endoscopy: Current status and future directions

Colon capsule endoscopy (CCE; PillCam Colon; Given Imaging; Yoqneam, Israel) is a minimally invasive wireless technique for the visualization of the colon. With the recent introduction of the second generation colon capsule the diagnostic accuracy of CCE for polyp detection has significantly improved and preliminary data suggest it may be useful to monitor mucosal inflammation in patients with inflammatory bowel disease. Limitations include the inability to take biopsies and the procedural costs. However, given the potentially higher acceptance within an average risk colorectal cancer (CRC) screening population, its usefulness as a screening tool with regard to CRC prevention should be further evaluated.

Current applications and potential future role of wireless capsule technology in Crohn's disease

BACKGROUND

The development of capsule technology has modified our approach to the diagnosis of gastrointestinal disease. The relatively rapid uptake of capsule endoscopy as an important clinical tool can be largely ascribed to a number of key factors, including the fact that it is a relatively easy examination to perform in an outpatient setting. It has been established as an integral part of the investigation pathway for obscure gastrointestinal bleeding and suspected small bowel Crohn's disease (CD). CURRENT USE OF CAPSULE ENDOSCOPY: Small bowel CD can be a challenging entity to diagnose. Capsule endoscopy has been shown to be both useful and safe in patients with both suspected and established small bowel CD. In suspected disease, capsule endoscopy has both a high diagnostic yield and negative predictive value. Capsule findings lead to changes in management in up to 73% of patients with established CD. However, while the technology appears capable of detecting subtle mucosal changes not readily apparent on alternate imaging modalities, the question of what actually constitutes small bowel CD as described by capsule is an issue that remains unresolved to date. Thus, capsule endoscopy is best utilised in tandem with advanced imaging and endoscopic techniques such as balloon- assisted enteroscopy.

FUTURE DEVELOPMENTS

The development of a capsule capable of viewing the colon coupled with improvements in image quality and battery life are likely to lead to the increasing uptake of this technology. In the future, 'interactive' capsules with the ability to view the entire gastrointestinal tract may be a reality.

Is there a role for colon capsule endoscopy beyond colorectal cancer screening? A literature review

Colon capsule endoscopy is recommended in Europe alternatively to colonoscopy for colorectal cancer screening in average risk individuals. The procedure has also been proposed to complete colon examination in cases of incomplete colonoscopy or when colonoscopy is contraindicated or refused by the patient. As tissue samples cannot be obtained with the current capsule device, colon capsule endoscopy has no place in diagnosing ulcerative colitis or in dysplasia surveillance. Nevertheless, data are accumulating regarding its feasibility to examine ulcerative colitis disease extent and to monitor disease activity and mucosal healing, even though reported results on the capsule's performance in this field vary greatly. In this review we present the currently available evidence for the use of colon capsule endoscopy to complement colonoscopy failure to reach the cecum and its use to evaluate ulcerative colitis disease activity and extent. Moreover, we provide an outlook on issues requiring further investigation before the capsule becomes a mainstream alternative to colonoscopy in such cases.

Wireless capsule endoscopy of the large intestine: a review with future projections

PURPOSE OF REVIEW

Video capsule endoscopy, which was initially developed for exploring the small bowel, has been adapted for investigating the colon. This review summarizes recent developments in colon capsule technology as well as indications for its use.

RECENT FINDINGS

Second-generation PillCam colon capsule endoscopy (CCE-2) has been recently developed and has significantly improved the sensitivity and specificity of colon capsules for detecting polyps and/or tumors in patients with suspected or known colonic lesions. The use of CCE-2 has been shown to be of value in patients with incomplete standard colonoscopy. The use of CCE-2 has also been investigated in patients with ulcerative colitis and in outpatient settings. Several trials have tried to simplify the colon preparation regimen.

SUMMARY

Colon capsule endoscopy is a novel technique for exploring the colon. CCE-2 has improved the diagnostic capability of this noninvasive method. There is still room for improvement and simplification of colon preparation regimens. Apart from detection of polyps or neoplasms, colon capsule endoscopy has also been assessed in patients with inflammatory bowel disease.

Modified bowel preparation regimen for use in second-generation colon capsule endoscopy in patients with ulcerative colitis

BACKGROUND AND AIM

We have reported that second-generation colon capsule endoscopy (CCE-2) might be feasible for assessing the severity of mucosal inflammation in ulcerative colitis (UC). However, because of the low rate (69%) of complete evaluation of the colon and owing to inadequate cleansing. We believe that the method of bowel preparation could be improved by reducing volume. In the present study, we attempted to improve the colon-cleansing regimen in order to optimize the usefulness of CCE-2 in the management of UC patients.

METHODS

Twenty patients with histologically confirmed UC were enrolled. Patients took a maximum 2.2 L lavage solution (polyethylene glycol solution and magnesium citrate) in two or three divided doses. To assess the effectiveness of the modified bowel preparation regimen, we evaluated the rate of total colonobservation, the effectiveness of bowel cleansing, andinterobserver agreement in assessing UC disease activity. We used a four-point grading scale (poor, fair, good, and excellent) for evaluating the quality of bowel cleansing. Matts' endoscopic score was used to evaluate disease activity.

RESULTS

The rate of total colon observation was 85%, and 15 patients (75%) excreted the CCE-2 within 8 h. The proportion of excellent plus good cleansing was approximately 60%. There was a substantial interobserver agreement (κ = 0.777) in assessment of overall cleansing, which was still substantial at the fair cleansing level (κ = 0.700).

CONCLUSION

Using CCE-2, the modified bowel preparation regimen, with reduced volume has the potential to succeed in the evaluation of mucosal severity in UC.

Capsule endoscopy in patients refusing conventional endoscopy

Capsule endoscopy is nowadays the diagnostic technique of choice in the study of small bowel pathologies, allowing the non-invasive study of the entire mucosa. This has led, together with new technical advances, to the creation of two new models (PillCam ESO and PillCam Colon) for the study of esophageal and colonic diseases. These two new capsules offer an interesting alternative to conventional endoscopy in the study of the upper and lower digestive tracts, because traditional endoscopy is often unpleasant and uncomfortable for the patient, can be painful, often requires moderate or deep sedation and is not without complications (hemorrhage, perforation, etc.). PillCam Colon is particularly important for its usefulness in the diagnosis of colonic polyps, and is a potentially useful tool in cases of incomplete colonoscopy or in colorectal cancer screening, even more when most patients are reluctant to undergo screening programs due to the said disadvantages of conventional colonoscopy. This article discusses the advantages of capsule endoscopy over conventional endoscopy, its current application possibilities and indications in routine clinical practice. In the various sections of the work, we assess the application of endoscopic capsule in different sections of the digestive tract (esophagus, stomach, and colon) and finally the potential role of panendoscopy with PillCam Colon.

Robotics in Colonoscopy

Colorectal cancer is the second leading cause of mortality in men and women in the United States. While there is a definite advantage regarding the use of colonoscopies in screening, there is still a lack of widespread acceptance of colonoscopy use in the general public. This is evident by the fact that up to 75% of patients diagnosed with colorectal cancer present with locally advanced disease. In order to make colonoscopy and in turn colorectal cancer screening a patient friendly and a comfortable test some changes in tool are necessary. The conventional colonoscope has not changed much since its development. There are several new advances in colorectal screening practices. One of the most promising new advances is the advent of robotic endoscopic techniques.

Role of capsule endoscopy in inflammatory bowel disease

Videocapsule endoscopy (VCE) has revolutionized our ability to visualize the small bowel mucosa. This modality is a valuable tool for the diagnosis of obscure small bowel Crohn’s disease (CD), and can also be used for monitoring of disease activity in patients with established small-bowel CD, detection of complications such as obscure bleeding and neoplasms, evaluation of response to anti-inflammatory treatment and postoperative recurrence following small bowel resection. VCE could also be an important tool in the management of patients with unclassified inflammatory bowel disease, potentially resulting in reclassification of these patients as having CD. Reports on postoperative monitoring and evaluation of patients with ileal pouch-anal anastomosis who have developed pouchitis have recenty been published. Monitoring of colonic inflammatory activity in patients with ulcerative colitis using the recently developed colonic capsule has also been reported. Capsule endoscopy is associated with an excellent safety profile. Although retention risk is increased in patients with small bowel CD, this risk can be significanty decreased by a routine utilization of a dissolvable patency capsule preceding the ingestion of the diagnostic capsule. This paper contains an overview of the current and future clinical applications of capsule endoscopy in inflammatory bowel disease.

Role of capsule endoscopy Pillcam COLON 2 in patients with known or suspected Crohn's disease who refused colonoscopy or underwent incomplete colonoscopic exam: a case series

BACKGROUND

Almost 70-80 % of patients with Crohn's disease and virtually all patients with ulcerative colitis have colorectal mucosa involvement. Colon capsule endoscopy is an interesting option for patients unable or unwilling to undergo colonoscopy. We report our experience with the second-generation colon capsule PillCam(®) COLON 2 in the detection of significant lesions in patients with known or suspected Crohn's disease, who refused colonoscopy or underwent incomplete colonoscopic exam.

METHODS

We have retrospectively reviewed the results of capsule endoscopy in 6 patients who refused colonoscopy (n = 3) or underwent incomplete colonoscopic exam (n = 3) between March 2011 and October 2012. In all patients, a CT scan was obtained before capsule endoscopy to rule out significant stenosis.

RESULTS

In our series of 6 patients, 4 had both small bowel and colonic involvement. The use of the PillCam(®) COLON 2 capsule allowed a thorough examination and evaluation of the mucosal lesions with high acceptability, the method being perceived as noninvasive by the patients. No adverse events related to the capsule or bowel preparation were recorded.

CONCLUSION

In this patient population, PillCam(®) COLON 2 capsule endoscopy was safe. The capsule findings had an important impact on treatment decisions and patient management.