Capsule retentions and incomplete capsule endoscopy examinations: an analysis of 2300 examinations

Retention of endoscopic capsules in diverticula: Literature review of a capsule endoscopy rarity

Background and study aims This review aimed to provide an updated and comprehensive review of capsule retention within diverticula, shedding light on the characteristics and management of this rare event in capsule endoscopy. Methods A systematic literature search was conducted across multiple databases. All observational studies that reported capsule retention in a diverticulum among complication and outcomes, as well as case reports and series, were included. Manual cross-checking of references was also performed. Two extractors performed abstract and full-text reviews, as well as data-extraction. Results We found 167 references from Pubmed, Embase, and Web Of Science. Sixty-five duplicates were removed and another 71 references were excluded. Crosschecking of references found additional two articles. In total, 32 articles were included, resulting in a total of 34 cases of retained capsules in diverticula. The median age was 69 and the majority of the patients were male (76.5%). The most common retention occurred in Meckel's diverticulum (32.4%) followed by Zenker's diverticulum (20.6%). Investigation of capsule retention was done with x-ray (50%) and computed tomography (CT) scan (44.1%). Seventeen cases (50%) were asymptomatic. Resolution of the retention happened with endoscopy (35.3%) and surgical management (32.4%), as well as self-resolution (20.6%). Conclusions Due to the small number of cases, diverticula are not a risk factor for incomplete capsule endoscopy examination. It affects mainly elderly, male, asymptomatic patients, and typically is diagnosed with x-rays and CT scans. The most common type is Meckel's diverticulum, and endoscopy is the primary management. Capsule endoscopy retentions are extremely rare, with only 34 cases reported since the technology's introduction.

Robotic wireless capsule endoscopy: recent advances and upcoming technologies

Wireless capsule endoscopy (WCE) offers a non-invasive evaluation of the digestive system, eliminating the need for sedation and the risks associated with conventional endoscopic procedures. Its significance lies in diagnosing gastrointestinal tissue irregularities, especially in the small intestine. However, existing commercial WCE devices face limitations, such as the absence of autonomous lesion detection and treatment capabilities. Recent advancements in micro-electromechanical fabrication and computational methods have led to extensive research in sophisticated technology integration into commercial capsule endoscopes, intending to supersede wired endoscopes. This Review discusses the future requirements for intelligent capsule robots, providing a comparative evaluation of various methods' merits and disadvantages, and highlighting recent developments in six technologies relevant to WCE. These include near-field wireless power transmission, magnetic field active drive, ultra-wideband/intrabody communication, hybrid localization, AI-based autonomous lesion detection, and magnetic-controlled diagnosis and treatment. Moreover, we explore the feasibility for future "capsule surgeons".

Multicenter prospective registration study of efficacy and safety of capsule endoscopy in Crohn's disease in Japan (SPREAD-J study)

BACKGROUND

Evidence of small-bowel capsule endoscopy (SBCE) for evaluating lesions in Crohn's disease (CD) is lacking. We aimed to clarify the effectiveness and safety of SBCE in a large sample of patients with CD.

METHODS

This multicenter prospective registration study recorded the clinical information and SBCE results of patients with definitive CD (d-CD) or suspected CD (s-CD). The primary outcomes were the rates of successful assessment of disease activity using SBCE, definitive diagnosis of CD, and adverse events. Secondary outcomes were the assessment of SBCE findings in patients with d-CD and s-CD and factors affecting SBCE incompletion and retention; and tertiary outcomes included the association between clinical disease activity or blood examination, endoscopic disease activity, ileal CD, and the questionnaire assessment of patient acceptance of SBCE.

RESULTS

Of 544 patients analyzed, 541 underwent SBCE with 7 (1.3%) retention cases. Of 468 patients with d-CD, 97.6% could be evaluated for endoscopic activity. Of 76 patients with s-CD, 15.8% were diagnosed with 'confirmed CD'. CD lesions were more frequently observed in the ileum and were only seen in the jejunum in 3.4% of the patients. Male sex and stenosis were risk factors for incomplete SBCE, and high C-reactive protein levels and stenosis were risk factors for capsule retention. In L1 (Montreal classification) patients, clinical remission was associated with endoscopic remission but showed low specificity and accuracy. The answers to the acceptability questionnaire showed the minimal invasiveness and tolerability of SBCE.

CONCLUSION

SBCE is practical and safe in patients with CD.

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.

Quality indicators for capsule endoscopy and deep enteroscopy

BACKGROUND AND AIMS

Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method.

METHODS

An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method.

RESULTS

The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE.

CONCLUSIONS

Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

Quality Indicators for Capsule Endoscopy and Deep Enteroscopy

INTRODUCTION

Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method.

METHODS

An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method.

RESULTS

The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE.

DISCUSSION

Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

Clinical impact of videocapsule and double balloon enteroscopy on small bowel bleeding: Results from a large monocentric cohort in the last 19 years

BACKGROUND

Suspected small bowel bleeding (SSBB) is the main indication for videocapsule endoscopy (VCE) and double balloon enteroscopy (DBE). We assessed the impact of both modalities in a large cohort of SSBB patients in a European tertiary center.

METHODS

We retrospectively evaluated consecutive patients with SSBB undergoing VCE and/or DBE from March 2001 to July 2020. Demographic/clinical parameters, anticoagulant therapies, technical characteristics and adverse events were collected, as well as diagnostic yield (DY), VCE-DBE concordance, hemoglobin (Hb) values before and after DBE, and complications.

RESULTS

807 VCEs and 407 DBEs were performed in 751 patients. The DY was significantly higher in DBE compared with VCE (68.8% vs 57.7%), with the highest (75%) yield for overt active SB bleeding. The agreement between VCE and DBE was generally suboptimal (k = 0.059). This improved in cases where both procedures were done within 1-5 days of the other (k = 0.323). Post-procedural Hb values were significantly higher. In patients treated with direct oral anticoagulants (DOACs), there were no differences in DY, complications or Hb values compared with non-DOAC patients.

CONCLUSION

VCE and DBE play a pivotal role in the diagnostic and therapeutic approach to SSBB, having a high clinical impact even in patients treated with DOACs.

Endoscopy Capsule Retention in a Young Female with Small Bowel Strictures Secondary to Non-Steroidal Anti-Inflammatory Drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) can cause small bowel damage, which could present in different ways, including abdominal pain and occult gastrointestinal bleeding. NSAID use can also result in small bowel strictures, which can be challenging to diagnose and manage. Here, we describe a case of a 49-year-old female who presented with chronic anaemia and intermittent abdominal pain, with a history of NSAID use. She underwent capsule endoscopy as part of the workup for anaemia and subsequently had capsule retention due to a small bowel stricture.

Can we predict an incomplete capsule endoscopy? Results of a multivariate analysis using a logistic regression model

BACKGROUND AND AIMS

Small bowel capsule endoscopy (SBCE) does not reach the cecum within the battery lifetime in approximately 15-35% of patients. Incomplete examinations result in diagnostic delays and increase the economic burden. To date, risk factors for incomplete examinations have been described with contradictory results. The aims of this study were to analyze rate and identify risk factors for incomplete examinations, excluding capsule retentions, in a large cohort of patients.

METHODS

Data from 1894 consecutive SBCE examinations performed from January 2009 to December 2015 were analyzed. Variables recorded included demographics, past medical and surgical history, biochemical parameters and procedure characteristics. The rate of incomplete examinations, excluding capsule retentions, was calculated and a multivariate analysis using a logistic regression model was performed in order to evaluate predictive factors.

RESULTS

The incidence of incomplete examinations, excluding capsule retentions, was 10.1% (187 incomplete procedures). The multivariate analysis showed that age >65 years, gastric transit time >41 minutes and SB transit time >286 minutes are predictive factors for incomplete examinations, increasing the probability of this event by 199% (OR:1.99; CI95%:1.34-2.95), 260% (OR:2.60; CI95%:1.72-3.93) and 352% (OR:3.52; CI95%:2.26-5.48), respectively.

CONCLUSIONS

Age >65 years, gastric transit time >41 minutes and SB transit time >286 minutes are predicting factors for incomplete examinations excluding capsule retentions. Both age and gastric transit time events are known before procedure ending. Therefore, pharmacologic or endoscopic measures may be taken into account to avoid incomplete examinations.

The role of small-bowel endoscopy in inflammatory bowel disease: an updated review on the state-of-the-art in 2021

The impact of small-bowel (SB) capsule endoscopy and device-assisted enteroscopy on clinical practice, since their introduction 2 decades ago, has been remarkable. These disruptive technologies have transformed the investigation and management of SB pathology and now have a firmly established place in guidelines and clinical algorithms. Furthermore, recent years have witnessed innovations, driven by the demand of new goals in the management of inflammatory bowel disease (IBD), such as mucosal healing and evolving strategies based on tight monitoring and accelerated escalation of care. These developments in SB endoscopy have also been paralleled by refinement in dedicated radiological SB imaging technologies. This updated review highlights the current state of the art and more recent innovations with a focus on their role in IBD.

Feasibility and diagnostic yield of small-bowel capsule endoscopy in patients with surgically altered gastric anatomy: the SAGA study

BACKGROUND AND AIMS

Little is known about small-bowel (SB) capsule endoscopy (CE) in patients with a history of gastric surgery. This study aims to evaluate the feasibility and diagnostic yield (DY) of orally ingested SB-CE in patients with surgically altered gastric anatomy.

METHODS

Twenty-four European centers retrospectively identified patients who had SB-CE after total or subtotal gastrectomy. The primary outcome was the DY of SB-CE (intermediate P1 to highly P2 relevant findings). Secondary outcomes were gastric and SB transit times, completion, cleanliness, and adverse event rates.

RESULTS

Studied were 248 procedures from 243 patients (mean age, 62 years) with a history of partial gastrectomy (Billroth I, 13.1%; Billroth II, 34.6%), total gastrectomy (7.4%), Whipple procedure (12.8%), sleeve gastrectomy (7.2%), or gastric bypass surgery (24.7%). Obscure GI bleeding was the most frequent indication (85.1%). SB completion rate was 84.3%. One capsule retention in the SB was noted (adverse event rate, .4%). Median SB transit time was 286 minutes (interquartile range [235; 387]). Cleanliness was rated as adequate in 92.1% of procedures. After exclusion of abnormalities found at the upper anastomotic site, the DY was 43.6%, with inflammatory/ulcerated lesions observed more frequently (23.4%) than vascular lesions (21.0%).

CONCLUSIONS

SB-CE seems to be feasible and safe in selected patients with a history of major gastric surgery and comes with a high DY. The spectrum of abnormal SB findings in these patients may be different from what is known from the literature in nonoperated patients.

Undiagnosed Endoscopy Capsule Retention Causing Delayed Intestinal Obstruction in a Patient with a Small Bowel Neuroendocrine Tumor

BACKGROUND Capsule endoscopy has played a significant role in small bowel investigation, providing the opportunity of detecting neoplastic lesions to a greater degree and at an earlier stage than other diagnostic procedures. Failure to excrete the capsule with the feces within 48 h can lead to capsule retention with increased risk of further complications such as bowel obstruction and perforation. Capsule retention can remain undetected in case of incomplete follow-up and poor patient compliance. Acute small bowel obstruction as late as many months following capsule endoscopy investigation is very rare, with only a few cases reported in the published literature. We herein report a rare case of prolonged capsule retention which remained undiagnosed, resulting in small bowel obstruction 6 months after the initial investigation. CASE REPORT An 82-year-old woman presented with abdominal pain and symptoms suggestive of intestinal obstruction. The patient history included a capsule endoscopy investigation because of episodes of abdominal pain 6 months prior to admission. Both the outcome of the investigation and the excretion of the capsule remained undetermined due to her history of dementia and follow-up failure. Radiologic investigations identified the capsule causing small bowel obstruction. Upon surgery, the capsule was found to be impacted in a stenotic small bowel lesion, and a segmental small bowel resection was performed. Histologic examination revealed the presence of a stenotic small bowel neuroendocrine tumor. CONCLUSIONS Appropriate follow-up is necessary to diagnose the complication of capsule retention which, if it remains unrecognized, can cause life-threatening complications as late as many months after capsule endoscopy.

Feasibility, complications, and quality of visualization using video capsule endoscopy in 40 dogs with overt or questionable gastrointestinal bleeding

Background

Prospective studies describing video capsule endoscopy (VCE), its feasibility, and complications in dogs are limited.

Objective

To assess VCE, quality of visualization, complications, and risk factors for incomplete studies in dogs with overt or questionable gastrointestinal bleeding (GIB).

Animals

Forty dogs with overt or questionable GIB.

Methods

Prospective, multicenter, interventional study. From August 2017 to March 2020, dogs were examined by VCE (ALICAM) because of overt or questionable GIB. Reported outcomes included diagnostic results of VCE study, quality of visualization, and complications. Risk factors for incomplete studies were evaluated using logistic regression.

Results

In total, 40 dogs (13 overt, 27 questionable GIB) were included. The capsules were administered PO in 29 and endoscopically in 11 dogs (6 duodenum, 5 stomach). One capsule was not retrieved. In 24 of 39 recordings, bleeding lesions were identified (10 overt GIB, 14 questionable GIB). Overall, the quality of visualization was poor to limited in the stomach and colon, and adequate to good in the small intestine. The most common complication was an incomplete study in 15/39 studies, particularly after oral administration (13/28). Risk factors for incomplete study after oral administration included administration of simethicone or opioids, chronic enteropathy, and capsule gastric transit time >6 hours.

Conclusions and Clinical Importance

Video capsule endoscopy can be used to diagnose a variety of lesions causing bleeding in the gastrointestinal tract of dogs with questionable GIB. Incomplete studies are the most common complications in dogs after oral administration of capsules.

Indications, Contraindications, and Considerations for Video Capsule Endoscopy

Video capsule endoscopy is indicated in a broad range of clinical settings, most commonly in evaluating suspected small bowel bleeding. It is also useful in diagnosing Crohn's disease and monitoring patients with known Crohn's. Video capsule endoscopy has a role in evaluating patients with refractory celiac disease symptoms and in surveying patients with polyposis syndromes. The only absolute contraindication to video capsule endoscopy is luminal gastrointestinal tract obstruction. Despite manufacturer statement, video capsule endoscopy can be used safely in patients with implantable cardiac devices including pacemakers, defibrillators, and ventricular assist devices.

Tag-less patency capsule for suspected small bowel stenosis: Nationwide multicenter prospective study in Japan

STUDY AIMS

The PillCam patency capsule (PPC) is an Agile tag-less patency capsule used to evaluate gastrointestinal (GI) patency. We determined the appropriate use of PPC to preclude subsequent small bowel capsule endoscopy (SBCE) retention.

METHODS

This prospective multicenter study consecutively enrolled patients indicated for SBCE with suspected or established small bowel stenosis. Excretion of an intact PPC or its radiologic visualization in the large bowel was considered GI patency. Primary and secondary study endpoints were SBCE retention rates in patients with confirmed patency and identification of factors associated with patency and SBCE retention, respectively.

RESULTS

Of 1096 patients enrolled in the study, patency was confirmed in 976 (89.1%). PPC excretion occurred in 579 patients. Of the remaining 517 patients, patency was confirmed using imaging modalities in 401 (77.5%). SBCE retention occurred in five (0.51%) of 963 patients who underwent SBCE: 1.0% in established Crohn's disease (CD) patients, 0% in suspected CD, 0% in tumors, and 1.6% in patients with obscure GI bleeding, for which PPC localization had been radiographically misinterpreted. The non-confirmation of patency was associated with established CD, stenosis identified using imaging modalities, abdominal fullness, serum albumin levels <4.0 g/dL, and previous small bowel obstruction (adjusted odds ratios: 4.21, 2.60, 2.47, 2.12, and 2.00; 95% confidence intervals: 2.62-6.78, 1.62-4.17, 1.43-4.27, 1.32-3.40, and 1.15-3.47, respectively).

CONCLUSIONS

The PillCam™ patency capsule helped preclude SBCE retention in most patients, but its accurate localization was essential for cases without excretion (Study registered the University Hospital Medical Information Network, #UMIN000010513).

Oral ingestion versus endoscopic delivery of endoscopic capsule in patients with previous gastrointestinal surgery (ORENCES study): A Spanish multicentre observational study

BACKGROUND

Small Bowel Capsule Endoscopy is the first-choice technique for investigating the majority of small bowel diseases. Its most common complications are related to incomplete examinations and capsule retention. There is no consensus on how patients with previous gastrointestinal surgery should receive the capsule.

OBJECTIVE

The primary endpoint was to compare the rate of complete small-bowel examinations (completion rate) between oral ingestion and endoscopic delivery of the capsule. The secondary endpoint was to compare diagnostic yield and adverse events in the two groups.

METHODS

A retrospective observational study was conducted in nine hospitals in Spain. Demographic data, previous surgery, indication for capsule endoscopy, intestinal transit time, diagnosis, completion rate (percentage of capsules reaching the caecum), diagnostic yield (percentage of results compatible with indication for the exam) and adverse events were collected.

RESULTS

From January 2009 to May 2019 fifty-seven patients were included (39 male, mean age 66±15 years). The most common indications for the exam were "overt" (50.9%) and "occult" (35.1%) small bowel bleeding. Previous Billroth II gastrectomy and Roux-en-Y gastric bypass were present in 52.6% and 17.5% of patients respectively. The capsule was swallowed in 34 patients and placed endoscopically in 23 patients. No significant differences were observed between the oral ingestion and endoscopic delivery groups in terms of completion rate (82.4% vs. 78.3%; p=0.742), diagnostic yield (41.2% vs. 52.2%; p=0.432) or small bowel transit time (301 vs. 377min, p=0.118). No capsule retention occurred. Only one severe adverse event (anastomotic perforation) was observed in the endoscopic delivery group.

CONCLUSIONS

In our case series, there were no significant differences between oral ingestion and endoscopic delivery in terms of completion rate, diagnostic yield or safety. Being less invasive, oral ingestion of the capsule should be the first-choice method in patients with previous gastrointestinal surgery.

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).

Clinical utility of the small bowel capsule endoscopy in the study of small bowel diseases in Colombia: Results of a national registry

INTRODUCTION

The small bowel capsule endoscopy (SBCE) has revolutionised the study of small bowel diseases. The objective of this study is to determine the indications, findings and diagnostic yield of SBCE in a national registry.

PATIENTS AND METHODS

An observational, analytical cross-sectional study was carried out, analysing the SBCE records at seven centres in the country, where different variables were collected.

RESULTS

1,883 SBCEs were evaluated. The average age was 55.4 years (5.6-94.2). The most frequent indications were suspicion of small bowel bleeding (SBB) (64.4%), study of Crohn's disease (15.2%) and chronic diarrhoea (11.2%). 54.3% were prepared with laxatives. The most frequent lesions found were erosions/ulcers (31.6%), angioectasias (25.7%) and parasitosis (2.7%). The diagnostic yield (P1+P2, Saurin classification) of SBCE in SBB was 60.6%, being higher in overt SBB (66.0%) compared to occult SBB (56.0%) (P=.003). The studies with better preparation showed higher detection of lesions (93.8% vs. 89.4%) (OR=1.8, CI: 95%: 1.2-2.6; P=.004). The SBCE complication rate was 3.1%, with complete SB visualisation at 96.6% and SB retention rate of 0.7%. 81.5% of SBCEs were performed on an outpatient basis, and presented a greater complete SB visualisation than hospital ones (97.1% vs. 94.3%) (OR=2.1, CI: 95%, 1.2-3.5; P=.008).

CONCLUSIONS

The indications, findings and diagnostic performance of SBCEs in Colombia are similar to those reported in the literature, with a high percentage of complete studies and a low rate of complications.

Clinical Impact of Small Bowel Capsule Endoscopy in Obscure Gastrointestinal Bleeding

Background and objectives: The most frequent indications for small bowel capsule endoscopy (SBCE) are obscure gastrointestinal bleeding (OGIB) and iron deficiency anemia (IDA). The aim of this study was to evaluate the diagnostic yield (DY) of SBCE in overt and occult OGIB, as well as its impact on the clinical outcome. Materials and Methods: This study retrospectively included all cases of OGIB investigated by SBCE in a tertiary care referral center, between 1st January 2016 and 31st December 2018. OGIB was defined by overt or occult gastrointestinal bleeding, with negative upper and lower endoscopy. Occult gastrointestinal bleeding was either proved by a fecal test or presumptively incriminated as a cause for IDA. DY was defined as the detection rate for what were thought to be clinically significant findings. DYs for overt and occult bleeding were assessed and compared. Gender, age, hemoglobin levels, NSAID consumption and the use of anticoagulants were recorded. Following SBCE results, individual therapeutic decisions were made, and follow-up data were recorded. Results: 224 SBCE examinations were performed for OGIB, of which 148 were for overt OGIB, and 76 for unexplained IDA. Positive findings were found in 139 patients, resulting in an overall DY for OGIB of 62%, higher in overt OGIB (75%) compared to IDA (37%). The most frequent findings were small bowel angioectasias (62.2% in overt OGIB and 78.5% in IDA). On multivariate logistic regression analysis, only hemoglobin level <10 g/dL and anticoagulants were the variables independently associated with positive findings. All patients received medical, endoscopic or surgical treatment and had good clinical outcome during follow-up. Conclusion: SBCE has a high diagnostic yield and a positive impact on management of patients with OGIB.

Use of prokinetics and other quality factors in capsule endoscopy - old and new insights (Review)

Despite the extensive recent development of different techniques for endoscopic evaluation for both diagnostic and therapeutic reasons, the small bowel remains quite difficult to visualize. Capsule endoscopy and device assisted enteroscopy are presently considered the best diagnostic tools for examination of small bowel disorders, assessing diverse pathologies such as obscure gastrointestinal bleeding, iron deficiency anemia, Crohn disease, small bowel tumors and polyposis syndromes. Like any other imagistic method, it has specific indications, and contraindications, and possibly it is more important to consider limitations. In order to obtain a better result, it is necessary to respect the procedural quality indicators. Among them the use of prokinetics - diverse pharmacological substances increasing the success rate of capsule endoscopy have raised debates. Capsule endoscopy small bowel evaluation is a reliable, non-invasive and safe with many advantages and minimum risks, with a proper selection of patients, and can be used as first line investigation.

A New Active Locomotion Capsule Endoscopy under Magnetic Control and Automated Reading Program

Capsule endoscopy (CE) is the first-line diagnostic modality for detecting small bowel lesions. CE is non-invasive and does not require sedation, but its movements cannot be controlled, it requires a long time for interpretation, and it has lower image quality compared to wired endoscopy. With the rapid advancement of technology, several methods to solve these problems have been developed. This article describes the ongoing developments regarding external CE locomotion using magnetic force, artificial intelligence-based interpretation, and image-enhancing technologies with the CE system.

Changes in performance of small bowel capsule endoscopy based on nationwide data from a Korean Capsule Endoscopy Registry

BACKGROUND/AIMS

Capsule endoscopy (CE) is widely used for the diagnosis of small bowel diseases. The clinical performance and complications of small bowel CE, including completion rate, capsule retention rate, and indications, have been previously described in Korea. This study aimed at estimating the recent changes in clinical performance and complications of small bowel CE based on 17-year data from a Korean Capsule Endoscopy Registry.

METHODS

CE registry data from 35 hospitals were retrospectively analyzed. Clinical information, including completion rate, capsule retention rate, and indications, was collected and analyzed. In addition, the most recent 5-year data for CE examinations were compared with the previous 12-year data.

RESULTS

A total of 4,650 CE examinations were analyzed. The most common indication for CE was obscure gastrointestinal bleeding (OGIB). The overall incomplete examination rate was 16% and the capsule retention rate was 3%. Crohn's disease was a risk factor for capsule retention. Inadequate bowel preparation was significantly associated with capsule retention and incomplete examination. An indication other than OGIB was a risk factor for incomplete examination. A recent increasing trend of CE diagnosis of Crohn's disease was observed. The most recent 5-year incomplete examination rate for CE examinations decreased compared with that of the previous 12 years.

CONCLUSION

The 17-year data suggested that CE is a useful and safe tool for diagnosing small bowel diseases. The incomplete examination rate of CE decreased with time, and OGIB was consistently the main indication for CE. Inadequate bowel preparation was significantly associated with capsule retention and incomplete examination.

Balloon-Assisted Enteroscopy for Retrieval of Small Intestinal Foreign Bodies: A KASID Multicenter Study

Background and Aims

Balloon-assisted enteroscopy (BAE) can be used to retrieve small intestinal foreign bodies (FBs). Here, we aimed at exploring the clinical usefulness of BAE for the retrieval of small intestinal FBs.

Methods

We retrospectively reviewed the medical records of 34 patients who underwent BAE to retrieve small intestinal FBs at 3 tertiary referral centers between April 2005 and June 2017.

Results

The retained materials included capsule endoscopes (CEs; n = 18 [52.9%]), self-expandable metal stents (SEMSs; n = 5 [14.7%]), biliary drainage catheters (n = 4 [11.8%]), gallstones (n = 3 [8.8%]), an embolization coil (2.9%), a needle, an intragastric bariatric balloon, and a razor blade. FBs were located or stuck in the ileum (n = 17 [50%]), jejunum (n = 16 [47.1%]), and an undetermined small intestinal segment (n = 1). Seventeen cases of FBs (50%; 7 CEs, 3 biliary drainage catheters, 3 SEMSs, 2 gallstones, 1 intragastric balloon, and 1 needle) were successfully retrieved enteroscopically. FBs of 4 asymptomatic patients (3 CEs and 1 razor blade) passed spontaneously. The remaining 13 patients underwent surgery for persistent or symptomatic FBs: 12 were successfully removed and 1 CE removal procedure failed due to severe peritoneal adhesions. The presence of symptoms was the only independent predictor of successful retrieval using BAE (odds ratio 13.40, 95% confidence interval 1.10–162.56, P = 0.042). BAE-related complications such as bowel perforation and acute pancreatitis occurred in 2 patients (5.9%).

Conclusions

BAE can be the first option for FB removal in the small intestine. The presence of symptoms was associated with successful enteroscopic retrieval.

Magnetic Resonance Enterography and Capsule Endoscopy in Patients Undergoing Patency Capsule for the Evaluation of Small Bowel Crohn's Disease: A Korean Clinical Experience

Objective

Studies comparing magnetic resonance enterography (MRE) and capsule endoscopy (CE) for the assessment of small bowel (SB) Crohn's disease (CD) are scarce in Korea. In addition, there is no Korean experience of patency capsule (PC) examination prior to CE. The primary aim of this study was to compare diagnostic yields of MRE and CE for the assessment of SB CD. Secondary objectives were to compare the detection rate of proximal SB lesions by each modality in the Montreal classification and evaluate the safety and feasibility of PC in Korean CD patients.

Methods

MRE was performed as the first examination to assess SB CD. PC examination and CE were then performed. Diagnostic yields of active SB disease by MRE and CE were then analyzed.

Results

Disintegration of the patency capsule was shown in 5 patients out of 26 patients, who did not undergo CE. These 5 patients were accounted as negative CE findings. Overall, MRE and CE detected 80.8% and 65.4% of active SB lesions of CD in 26 patients, respectively (P = 0.212). MRE and CE detected 0% (0/26) and 19.2% (5/26) (P = 0.051) of jejunal lesions, 30.8% (8/26) and 42.3% (11/26) (P = 0.388) of proximal ileal lesions, and 80.8% (21/26) and 53.8% (14/26) (P = 0.039) of terminal ileal lesions, respectively. According to the Montreal classification, MRE and CE independently detected proximal disease (L4) in 30.8% (8/26) and 53.8% (14/26) (P = 0.092), respectively.

Conclusions

The diagnostic yields of MRE and CE for the assessment of SB CD including proximal SB lesions were similar. MRE is a more objective tool for detecting clinically relevant stricture than PC although PC examination could be performed safely before CE to prove the patency of SB. This trial is registered with KCT0004305.

A Robotic Biopsy Endoscope with Magnetic 5-DOF Locomotion and a Retractable Biopsy Punch

Capsule endoscopes (CEs) have emerged as an advanced diagnostic technology for gastrointestinal diseases in recent decades. However, with regard to robotic motions, they require active movability and multi-functionalities for extensive, untethered, and precise clinical utilization. Herein, we present a novel wireless biopsy CE employing active five degree-of-freedom locomotion and a biopsy needle punching mechanism for the histological analysis of the intestinal tract. A medical biopsy punch is attached to a screw mechanism, which can be magnetically actuated to extrude and retract the biopsy tool, for tissue extraction. The external magnetic field from an electromagnetic actuation (EMA) system is utilized to actuate the screw mechanism and harvest biopsy tissue; therefore, the proposed system consumes no onboard energy of the CE. This design enables observation of the biopsy process through the capsule's camera. A prototype with a diameter of 12 mm and length of 30 mm was fabricated with a medical biopsy punch having a diameter of 1.5 mm. Its performance was verified through numerical analysis, as well as in-vitro and ex-vivo experiments on porcine intestine. The CE could be moved to target lesions and obtain sufficient tissue samples for histological examination. The proposed biopsy CE mechanism utilizing punch biopsy and its wireless extraction-retraction technique can advance untethered intestinal endoscopic capsule technology at clinical sites.

Capsule Retention in Crohn's Disease: A Meta-analysis

BACKGROUND

The main factor that limits wider utilization of capsule endoscopy (CE) in Crohn's disease (CD) is the potential risk of retention. The aim of this systematic review was to evaluate capsule retention rates in adult and pediatric CD and determine if retention risk is reduced in established CD (ECD) with patency capsule (PC) or magnetic resonance/computed tomography (MR/CT) enterography.

METHODS

Studies of CD patients undergoing CE that reported retention were identified. Pooled estimates for retention rates and relative risk in ECD to suspected CD (SCD) were calculated. All hypothesis tests were 2-sided; statistical significance was set at a P value of <0.05.

RESULTS

In the overall CD cohort, retention rates were 3.32% (95% confidence interval [CI], 2.62%-4.2%): 4.63% (95% CI, 3.42%-6.25%) and 2.35% (95% CI, 1.31%-4.19%) in ECD and SCD, respectively. Retention rates were 3.49% (95% CI, 2.73%-4.46%) and 1.64% (95% CI, 0.68%-3.89%) in adult and pediatric CD, respectively. Retention risk in adult ECD was 3.4 times higher than SCD, but there was no difference in retention risk in pediatric ECD compared with SCD. Retention rates in ECD were decreased after patency capsule (2.88%; 95% CI, 1.74%-4.74%) and MR/CT enterography (2.32%; 95% CI, 0.87%-6.03%).

CONCLUSIONS

In comparison with older literature, this meta-analysis demonstrates lower CE retention rates in SCD and ECD. Retention rates in pediatric CD were lower than in adult CD. Retention rates in adult ECD were higher than SCD, but there were no differences between pediatric ECD and SCD. Retention rates in ECD were lower after negative PC or MR/CT enterography.

Outcomes and Management Strategies for Capsule Retention: A Korean Capsule Endoscopy Nationwide Database Registry Study

BACKGROUND

The most concerning complication of capsule endoscopy (CE) is capsule retention (CR) in the gastrointestinal (GI) tract; however, the clinical outcomes and management of patients with CR are still uncertain.

AIMS

This study aimed to investigate the clinical outcomes and management of CR.

METHODS

The outcomes of CR in multiple centers between October 2002 and June 2018 were retrospectively reviewed. Data on CE indication, findings, and management details were analyzed.

RESULTS

A total of 2705 consecutive small-bowel CE procedures were performed. CR was detected in 20 cases (0.7%). The most common site of CR was the small bowel (19 cases), followed by the esophagus (one case). In patients who underwent CE, CR was detected in nine (0.6%) of 1397 patients with obscure GI bleeding. Further, CR occurred in 11 (6.5%) of 169 patients with Crohn's disease based on the final diagnoses after CE. Capsule retrieval was safely performed surgically in nine cases and endoscopically in six cases. The retained capsules dislodged after steroid treatment in two cases, whereas three cases of CR resolved without any intervention. In multivariate analysis, the development of abdominal symptoms after CR was a significant predictive factor for requiring endoscopic or surgical interventions for capsule extraction.

CONCLUSIONS

This large multicenter study shows that CR is a rare complication with favorable clinical outcomes. Three-fourths of the patients with CR were managed with endoscopic or surgical intervention, which was required particularly in patients with abdominal symptoms after CR.

Predictive factors of an incomplete examination and inadequate small-bowel cleanliness during capsule endoscopy

AIM

the aim of this study was to determine predictive factors for an incomplete capsule endoscopy and an inadequate small-bowel preparation in capsule endoscopy.

METHODS

predictive factors for an incomplete capsule endoscopy were evaluated. Therefore, all patients with incomplete examinations performed between June 2009 and February 2016 were retrospectively included and compared with all patients with complete procedures performed between January 2014 and February 2016. Predictive factors of an inadequate small-bowel cleanliness were assessed. Therefore, the subset of patients that underwent capsule endoscopy between January 2014 and February 2016, including incomplete examinations, were evaluated. Small-bowel cleanliness was evaluated according to a quantitative index and a qualitative evaluation scale. Data with regard to patient and capsule endoscopy was analyzed.

RESULTS

31 incomplete and 122 complete capsule endoscopies were included in the analysis of predictive factors for an incomplete capsule endoscopy. The degree of dependency (OR = 4.67; p = 0.028), performance of a capsule endoscopy in hospitalized patients (OR = 4.04; p = 0.006) and prior abdominal surgery (OR = 3.45; p = 0.012) were independent predictive factors of an incomplete procedure. 130 patients were included in the analysis of predictive factors for an inadequate small-bowel cleanliness. The mean quantitative index value was 7.3 (s.d. ± 2.3); 41.6% and 58.5% of capsule endoscopies were classified as poor-fair and good/excellent respectively, according to the qualitative evaluation. Independent predictive factors for an inadequate preparation according to the quantitative index included male gender (Beta = -0.79; p = 0.028), small-bowel transit time (Beta = -0.007; p < 0.0001) and cardiac disease (Beta = -1.29; p = 0.001). Associated factors according to the qualitative evaluation included male gender (OR = 0.406; p = 0.027) and small-bowel transit time (SBTT) (OR = 0.993; p < 0.0001).

CONCLUSION

inpatient status, higher degrees of dependency and abdominal surgery are predictive factors for an incomplete capsule endoscopy; male gender and higher small-bowel transit time are predictive factors for an inadequate cleanliness.

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.

The Clinician's Guide to Suspected Small Bowel Bleeding

Small bowel bleeding accounts for 5-10% of gastrointestinal bleeding. With the advent of capsule endoscopy, device-assisted enteroscopy, and multiphase CT scanning, a small bowel source can now be found in many instances of what has previously been described as obscure gastrointestinal bleeding. We present a practical review on the evaluation and management of small bowel bleeding for the practicing clinician.

No significant difference in clinically relevant findings between Pillcam® SB3 and Pillcam® SB2 capsules in a United States veteran population

BACKGROUND

Capsule endoscopy (CE) allows for a non-invasive small bowel evaluation for a wide range of gastrointestinal (GI) symptoms and diseases. Capsule technology has been rapidly advancing over recent years, often improving image frequency and quality. The Pillcam^® SB3 (SB3) capsule is one such technology that offers an adaptive frame rate advantage over the previous versions of the capsule the Pillcam^® SB2 (SB2). Some have proposed that this improvement in capsule technology may lead to increased diagnostic yields; however, real world clinical data is currently lacking.

AIM

To evaluate the clinically relevant findings of SB3 and SB2 capsules in a population of United States veterans.

METHODS

A retrospective analysis of 260 consecutive CE studies was performed including 130 SB3 and 130 SB2 capsule studies. Recorded variables included: age, gender, type of capsule, body mass index, exam completion, inpatient status, opioid use, diabetes, quality of preparation, gastric transit time, small bowel transit time, indication, finding, and if the exam resulted in a change in clinical management. The primary outcome measured was the detection of clinically relevant findings between SB3 and SB2 capsules.

RESULTS

Mean age of the study population was 67.1 ± 10.4 years and 94.2% of patients were male. Of these 28.1% were on opioid users. The most common indications for capsule procedure were occult GI bleeding (74.6%) and overt GI bleeding (14.6%). Rates of incomplete exam were similar between SB3 and SB2 groups (16.9% vs 9.2%, P = 0.066). The overall rate of clinically relevant finding was 48.9% in our study. No significant difference was observed in SB3 vs SB2 capsules for clinically relevant findings (46.2% vs 51.5%, P = 0.385) or change in clinical management (40.8% vs 50.0%, P = 0.135).

CONCLUSION

Our study found no significant difference in clinically relevant findings between SB3 and SB2 capsules.

Small-Bowel Capsule Endoscopy in Clinical Practice: Has Anything Changed Over 13 Years?

BACKGROUND

In Lombardia, one of the 20 Italian administrative Regions, small-bowel capsule endoscopy (SBCE) was introduced in 2001. In January 2011, the Regional Health Authorities established a reimbursement for outpatient SBCE.

AIM

To prospectively record data on SBCE between 2011-2013 and compare them to similar data retrospectively collected from the same geographical area (covering the period 2001-2008) and published in 2008.

METHODS

Consecutive SBCEs performed between January 2011 and December 2013 in Lombardia were prospectively collected.

RESULTS

In 3 years, 3142 SBCEs were collected; the diagnostic yield (DY) and the overall complication rate were 48.4 and 0.9%, respectively. The main indication was suspected small-bowel bleeding (76.6% of patients); complete small-bowel inspection was achieved in 2796 (89.0%) patients. SBCE was performed as an outpatient procedure in 1945 patients (61.9%). A significant increase in the rate of patients undergoing SBCE for suspected small-bowel bleeding was observed from 2001-2008 to 2011-2013 (67.3 vs. 76.1%; p < 0.001). There was an increase in the number of complete small-bowel examinations (81.2 vs. 89.0%; p < 0.001) and of outpatient SBCEs (6.7 vs. 61.9%; p < 0.001). Conversely, both the retention rate (2.1 vs. 0.8%; p < 0.001) and the rate of patients undergoing SBCE for Crohn's disease (11.5 vs. 5.5%; p < 0.001) decreased significantly. The overall DY remained stable (50.6 vs. 48.4%; p = 0.089).

CONCLUSION

Our study shows that, over 13 years, the SBCE safety profile and completion rate significantly improved over time; a change in the spectrum of clinical indications was also observed.

What defines quality in small bowel capsule endoscopy

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

Small bowel tumours: update in diagnosis and management

PURPOSE OF REVIEW

The aim of this study was to summarize the role of recently developed diagnostic techniques in the diagnosis and management of patients with small bowel tumours (SBTs).

RECENT FINDINGS

Recent studies show that the overall SBT incidence is increasing. The introduction of small bowel dedicated diagnostic tools [i.e. capsule endoscopy, device-assisted enteroscopy (DAE), computed tomography (CT) and MRI-enterography] might partially explain this trend. In patients with SBT, DAE might represent an ideal tool by coupling careful mucosal inspection with sampling capability. Unfortunately, DAE is an invasive procedure and seldom allows complete small bowel evaluation in a single setting. Therefore, DAE is more often used in clinical practice as confirmatory tool, when other less invasive and readily available tests (i.e. capsule endoscopy or radiological tests) identify relevant findings. Nevertheless, in patients with SBT, capsule endoscopy is burdened by an increased risk of capsule retention and/or missing proximal small bowel lesions, whereas dedicated cross-sectional imaging techniques often identify nonspecific findings of limited clinical significance.

SUMMARY

Despite recent technical improvements, in patients with SBT, the result of a single diagnostic procedure is often insufficient to provide a definite diagnosis. A balanced combination of different tests allows reaching a final diagnosis and drive further management.

Small bowel bleeding: cause and the role of endoscopy and medical therapy

PURPOSE OF REVIEW

The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias.

SUMMARY

SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.

Risk factors for surgery in patients with retention of endoscopic capsule

OBJECTIVES

Surgery is still the main means for removing retained endoscopic capsules. This study intended to evaluate risk factors for surgery in patients with capsule retention.

MATERIALS AND METHODS

The data of 5348 consecutive capsule endoscopy examinations were retrospectively analyzed. Cox regression analysis was used to evaluate risk factors.

RESULTS

Seventy-seven patients (1.4%) had capsule retention. Spontaneous passage occurred in 16 patients, of which 14 were asymptomatic. Successful retrieval by double-balloon enteroscopy (DBE) was achieved in 14 patients, of which 11 did not need surgery during clinical follow-up. A total of 50 patients underwent surgery. The cumulative rates of surgery were 44.2%, 53.2%, 55.8%, 62.3% and 64.9% at 1, 3, 6, 12 and 60 months after capsule retention, respectively. Intestinal obstruction [hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.12-3.76; p = .020] and overt small bowel bleeding (HR 2.01, 95%CI 1.08-3.71; p = .027) during capsule retention were independently associated with an increased risk for surgery. Specific treatment for primary disease (HR 0.22, 95%CI 0.07-0.74, p = .014) and successful endoscopic retrieval (HR 0.20, 95%CI 0.06-0.66; p = .008) were independently associated with a decreased risk for surgery.

CONCLUSIONS

For asymptomatic patients, specific medical treatment for primary disease can be maintained until the capsule spontaneously passes or symptoms appear. For patients with slight abdominal pain, DBE can be performed. For patients with intestinal obstruction or overt small bowel bleeding, early surgical consultation should be considered.

Oral delivery of biologics using drug-device combinations

Orally administered devices could enable the systemic uptake of biologic therapeutics by engineering around the physiological barriers present in the gastrointestinal (GI) tract. Such devices aim to shield cargo from degradative enzymes and increase the diffusion rate of medication through the GI mucosa. In order to achieve clinical relevance, these designs must significantly increase systemic drug bioavailability, deliver a clinically relevant dose and remain safe when taken frequently. Such an achievement stands to reduce our dependence on needle injections, potentially increasing patient adherence and reducing needle-associated complications. Here we discuss the physical and chemical constraints imposed by the GI organs and use these to develop a set of boundary conditions on oral device designs for the delivery of macromolecules. We critically examine how device size affects the rate of intestinal obstruction and hinders the loading capacity of poorly soluble protein drugs. We then discuss how current orally administered devices could solve the problem of tissue permeation and conclude that these physical methods stand to provide an efficacious set of alternatives to the classic hypodermic needle.

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.

Retention associated with video capsule endoscopy: systematic review and meta-analysis

BACKGROUND AND AIMS

Video capsule endoscopy (VCE) has become a major diagnostic tool for small-bowel evaluation. However, retention of the video capsule endoscope remains a major concern.

METHODS

We performed a systematic review of VCE retention rates by using Pubmed and SCOPUS (1995-2015). We included studies that enrolled at least 10 patients, included VCE retention rates, and separated retention rates by indication. We used Comprehensive Meta-Analysis (Version 3.0) to calculate pooled prevalence rates with 95% confidence intervals (CIs) and assessed heterogeneity by using the Cochran Q statistic.

RESULTS

We included 25 studies (N = 5876) for patients undergoing VCE for evaluation of potential small-bowel bleeding, 9 studies (N = 968) for patients with suspected inflammatory bowel disease (IBD), 11 studies (N = 558) for patients with established IBD, and 8 studies for patients (N = 111) undergoing VCE for evaluation of abdominal pain and/or diarrhea. We used a random effects model and found that the pooled retention rate was 2.1% for patients with suspected small-bowel bleeding (95% CI, 1.5%-2.8%). Retention rates were 3.6% (95% CI, 1.7%-8.6%) for suspected IBD, 8.2% (95% CI, 6.0%-11.0%) for established IBD, and 2.2% (95% CI, 0.9%-5.0%) for abdominal pain and/or diarrhea. Based on subgroup analysis, subsequent VCE completion rates after performance of a patency capsule or CT enterography in patients with IBD to exclude retentions due to strictures was 2.7% (95% CI, 1.1%-6.4%). Reasons for retention were provided in 60 (77%) studies. The most common reasons for retention were small-bowel strictures, although etiology was not provided in all studies.

CONCLUSION

VCE retention occurs in approximately 2% of patients undergoing evaluation for small-bowel bleeding and is most likely due to small-bowel strictures. Retention rates in patients with suspected or known IBD were approximately 4% and 8%, based on our meta-analysis. These rates decreased by half in those studies that used either a patency capsule or CT enterography to assess patency before performing VCE.

The impact of hospitalization on the performance of capsule endoscopy (CE)

BACKGROUND

For proper evaluation of capsule endoscopy (CE), a complete examination is necessary.

AIM

We evaluated risk factors of an incomplete CE with focus on patient hospitalization.

METHODS

We retrospectively evaluated 161 consecutive patients who underwent CE between 01.07.2013 and 13.03.2016. Main indications were active bleeding, iron deficiency anemia (IDA), inflammatory bowel disease (IBD), abdominal pain, and familial adenomatous polyposis (FAP).

RESULTS

We report the results of 103 in-patients and 56 out-patients. Eighty-two patients were male, average age was 58.9 years (range 18-90). Indications for CE were active bleeding (103 patients), IDA and IBD (16 patients), and FAP, abdominal pain and others (eight examinations each). All FAP patients were out-patients, but showed the longest small bowel transit time (SBTT) of 443.6min (p=0.0001). The shortest SBTT was found in out-patients without FAP (267.5min, p<0.05). In the in-patient group, nine endoscopies did not record the entire small bowel (8.7%) due to battery depletion, compared with only one incomplete examination in the out-patients (1.8%, p=0.036). We found pathologic lesions in the last 30min of the SBTT in 43 patients, and this indicates the necessity for complete examination. Thirteen of these 43 patients showed major lesions such as ulcers or angiodysplasia in this last region alone.

CONCLUSION

In-patients might require special treatment to ensure complete examination, since a considerable amount of pathologies can only be found in the ileum.

Colonic obstruction caused by video capsule entrapment in a metal stent

Video capsule endoscopy (VCE) has become the method of choice for visualizing the small bowel mucosa and is generally considered to be a safe method. Although uncommon, the most feared complication of VCE is capsule retention that can potentially lead to life-threatening bowel obstruction. Herein, we present for the first time a case of capsule retention in a colonic stent. The patient had known Crohn's disease with colonic involvement and underwent an uneventful but incomplete small bowel VCE for assessment of disease activity and extension for optimizing medical treatment. Five months later, the patient presented with intestinal obstruction due to a Crohn's-stricture in the sigmoid colon, which was successfully decompressed with a self-expandable metal stent. Nonetheless, two days later the patient showed signs of bowel obstruction again and abdominal X-ray showed that the capsule was trapped in the metal stent in the sigmoid colon. Subsequently, emergency surgery was performed and the patient fully recovered. Intestinal capsule retention necessitating interventional removal is rare. This report describes a unique case of capsule retention in a colonic metal stent and highlights the potential risk of performing capsule endoscopy examinations in patients with gastrointestinal stents.

Capsule retention: prevention, diagnosis and management

Capsule retention (CR) has been defined as capsule remaining in the digestive tract for a minimum of two weeks. CR occurs approximately in 2% of all patients undergoing small bowel capsule endoscopy (CE). Prompt diagnosis of CR is important, as it has relevant clinical implications. CR should be suspected in (I) all asymptomatic patients who do not report capsule excretion within 15 days from capsule ingestion; and (II) patients with obstructive or perforation-related symptoms in which the capsule has not been excreted, regardless of the time between the onset of symptoms and capsule ingestion. Abdominal plain X-ray is the preferred test to confirm CR. An abdominal CT scan should be performed, on individual basis, if knowledge of the precise location of the retained capsule is necessary or whenever clinically indicated. Since CR is usually asymptomatic, an initial watchful monitoring is suggested. In inflammatory bowel disease (IBD) patients, a short course of medical therapy may allow capsule excretion. Nevertheless, in long-term CR, some cases of capsule fragmentation, acute obstruction and perforation have been described. Therefore, retrieval of the retained capsule is recommended if asymptomatic CR lasts for long time. A safe capsule retrieval is usually performed by endoscopy, whereas surgery remains a viable alternative if the first is unsuccessful or when clinically indicated. Either Patency Capsule^® (PC) or dedicated small bowel cross-sectional imaging techniques have been proposed to prevent CR. Both have pros and cons, but head-to-head comparative studies are lacking.

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.

[When and how should small-bowel capsule endoscopy be used in children?]

Small-bowel capsule endoscopy (CE) has recently been used in children. During the past few years, an intense research activity has defined the advantages and limitations of CE. Its uses have been established in several small-bowel pathologies such as obvious or obscure digestive bleeding, Crohn disease, and hereditary polyposis. Although the absence of biopsy reduces the specificity of CE findings, small-bowel exploration using CE achieves better accuracy in detecting lesions than most radiological examinations. In children, swallowing problems and the risk of retention due to stenosis are the main concerns when using CE: these problems can be solved using endoscopic delivery of the capsule and luminal diameter calibration, respectively. This review focuses on the evidence making CE indispensable to small-bowel exploration.

NASPGHAN Capsule Endoscopy Clinical Report

Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.

Evidence-Based Guide on Capsule Endoscopy for Small Bowel Bleeding

Capsule endoscopy is the diagnostic test of choice for the evaluation of overt and occult small bowel bleeding. Its yield is higher in patients presenting with overt bleeding. The yield is also improved if the capsule is performed soon after the presentation of bleeding. Capsule endoscopy has a complementary role with cross-sectional imaging to triage patients for appropriate management, including deep enteroscopy, surgery, or, if negative, conservative management. Although capsule endoscopy is useful to detect vascular and inflammatory lesions, it appears to have a significant miss rate for solitary small bowel lesions, including tumors. The main adverse event is capsule retention in patients with underlying small bowel obstruction.