Capsule retention: prevention, diagnosis and management

Clinical application and feasibility of capsule endoscopy in children at a medical center in central Taiwan

BACKGROUND PURPOSE

Capsule endoscopy (CE) is a noninvasive examination for excellent visualization of small bowel mucosal lesions. We aimed to evaluate the clinical efficacy and safety of CE in pediatric patients.

METHODS

From April 2014 to December 2022, CE procedures performed in children younger than 18 years of age at Taichung Veteran General Hospital were analyzed retrospectively.

RESULTS

Among 136 procedures, the completion rate was 95.6% (n = 130), with a median age of 14 years old. Suspicion or evaluation of inflammatory bowel diseases (IBD) (41%) was the most common indication for CE. Other common indications of CE were chronic unexplained abdominal pain (35%) and obscure gastrointestinal bleeding or iron deficiency anemia (21%). No procedure-related complications occurred. The diagnosis of those patients with incomplete study were CD with small bowel stricture, graft-versus-host disease and duodenal ulcers. A total of 86 CE procedures showed positive findings, and the overall diagnostic yield rate was 63.2%. Small bowel ulcers (65.12%) were the most common findings. Overall, 26.5% of CE examinations resulted in a new diagnosis and 44.9% of CE exams led to a change in therapy. For patients with IBD, CE findings resulted in an even higher therapeutic change rate of 48.1%.

CONCLUSIONS

CE is a safe and feasible diagnostic method to study the small intestine in children, especially for IBD. Incomplete study could be an indicator of positive finding and can potentially be a guide to identify the site of possible strictures.

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.

Preclinical study of a novel ingestible bleeding sensor for upper gastrointestinal bleeding

BACKGROUND/AIMS

Upper gastrointestinal bleeding (UGIB) is a life-threatening condition that necessitates early identification and intervention and is associated with substantial morbidity, mortality, and socioeconomic burden. However, several diagnostic challenges remain regarding risk stratification and the optimal timing of endoscopy. The PillSense System is a noninvasive device developed to detect blood in patients with UGIB in real time. This study aimed to assess the safety and performance characteristics of PillSense using a simulated bleeding model.

METHODS

A preclinical study was performed using an in vivo porcine model (14 animals). Fourteen PillSense capsules were endoscopically placed in the stomach and blood was injected into the stomach to simulate bleeding. The safety and sensitivity of blood detection and pill excretion were also investigated.

RESULTS

All the sensors successfully detected the presence or absence of blood. The minimum threshold was 9% blood concentration, with additional detection of increasing concentrations of up to 22.5% blood. All the sensors passed naturally through the gastrointestinal tract.

CONCLUSION

This study demonstrated the ability of the PillSense System sensor to detect UGIB across a wide range of blood concentrations. This ingestible device detects UGIB in real time and has the potential to be an effective tool to supplement the current standard of care. These favorable results will be further investigated in future clinical studies.

Capsule endoscopy retention in the upper esophagus: A comprehensive literature review

Capsule endoscopy is the first-line investigation for small bowel disorders. Capsule retention in the small bowel is the most common adverse event. Retention has also been reported in the upper esophagus; however, guidance for diagnosis and management is lacking. This review aims to summarize the diagnostic workup and management of this complication. We conducted a systematic literature review by searching 5 databases; relevant keywords and MeSH terms were used. Exclusion criteria included publications of non-adult patients in non-English languages. Data from eligible studies were analyzed using IBM SPSS 29. Twelve case reports were found (9 males, median age of 76 years); 10 capsule retentions in Zenker's diverticulum and 2 in the cricopharyngeus. Most patients were asymptomatic before capsule endoscopy. Capsule retention was symptomatic in half of the patients (6/12). A neck X-ray confirmed the diagnosis in all patients. Endoscopic capsule retrieval was achieved by different tools (9/12) (Roth's net was the most used tool, 6 patients); retrieval required rigid endoscopy in a few cases (3/12). Endoscopic capsule re-insertion was successful; using an overtube to bypass the upper esophagus was the safest method. In conclusion, capsule retention in the upper esophagus is uncommon yet exposes patients to the risk of unnecessary procedures. Symptoms of swallowing and medium-to-large size Zenker's diverticulum should be considered contra-indications for capsule endoscopy. Neck and chest X-rays are required for elderly patients who do not pass the capsule 2 weeks after ingestion. Endoscopic retrieval using Roth's net and re-insertion through an overtube should be considered first-line management.

Patency testing improves capsule retention rates but at what cost? A retrospective look at patency testing

Capsule retention is one of the major complications of capsule endoscopy, which range from 2.1 to 8.2% depending on the indication. Over the last few years, reported rates of retention have fallen due to better patient selection due to the recognition of risk factors for capsule retention as well as the introduction of the patency capsule. The patency capsule is a dissolvable capsule with the same dimensions as the functional capsule. It breaks down in the GI tract after approximately 30 h, reducing the risk of symptomatic retention. Failure to pass this patency capsule out of the small bowel results in the patient being excluded from capsule endoscopy. We performed a retrospective analysis of the patency capsules performed in our unit over a 12-month period. A total of 166 (14.7%) of 1,127 patients referred for capsule endoscopy were deemed to require patency assessment (45.8% men, mean age 48 years). Of those who passed the patency assessment and underwent capsule endoscopy, no capsule retention was seen. Indication for patency assessment was found to be appropriate in 87.0% (n = 147). Overall, the failure rate at the patency assessment was 43.1%. The patency capsule remains an imperfect but useful tool in examining functional patency of the GI tract prior to capsule endoscopy.

Vibrating colon-stimulating capsule to treat chronic constipation: A systematic review

In August 2022, the United States Food and Drug Administration issued marketing authorization for an orally administered vibrating colon-stimulating capsule for treating chronic idiopathic constipation. We aimed to review the literature systematically and synthesize evidence on the role of the vibrating capsule in chronic idiopathic constipation. A comprehensive search was conducted on PubMed, Embase, International Clinical Trials Registry Platform (World Health Organization), Cochrane Library databases, and two pre-print servers (medRxiv.org and Research Square) until 31 December 2022, to identify published pre-clinical and clinical original studies evaluating the role of the vibrating capsule in patients with chronic constipation. The studies were critically analyzed, and data were extracted. We identified thirty-three articles and five studies (one pre-clinical, one combined, and three clinical). The pre-clinical studies in dogs revealed no adverse effects of the vibrating capsule. In the clinical studies, there were significant findings observed. The number of spontaneous bowel movements per week and the proportion of patients experiencing an increase of at least one complete spontaneous bowel movement per week were both significantly higher in the group receiving the vibrating capsule compared to the group receiving the sham capsule. No treatment-related serious adverse event was noted. The mild adverse events were vibration sensation, diarrhea, and abdominal discomfort. The efficacy and safety profiles of the vibrating colon-stimulating capsule in treating patients with chronic constipation are promising. However, more robust evidence is required by conducting large randomized clinical trials before conclusively determining its wider use.

Video Capsule Endoscopy Plays an Important Role in the Management of Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory disorder characterized by a transmural inflammation that may involve any part of the gastrointestinal tract. An evaluation of small bowel involvement, allowing recognition of disease extent and severity, is important for disease management. Current guidelines recommend the use of capsule endoscopy (CE) as a first-line diagnosis method for suspected small bowel CD. CE has an essential role in monitoring disease activity in established CD patients, as it can assess response to treatment and identify high-risk patients for disease exacerbation and post-operative relapse. Moreover, several studies have shown that CE is the best tool to assess mucosal healing as part of the treat-to-target strategy in CD patients. The PillCam Crohn's capsule is a novel pan-enteric capsule which enables visualization of the whole gastrointestinal tract. It is useful to monitor pan-enteric disease activity, mucosal healing and accordingly allows for the prediction of relapse and response using a single procedure. In addition, the integration of artificial intelligence algorithms has showed improved accuracy rates for automatic ulcer detection and the ability to shorten reading times. In this review, we summarize the main indications and virtue for using CE for the evaluation of CD, as well as its implementation in clinical practice.

Clinical guideline on magnetically controlled capsule gastroscopy (2021 edition)

With the development and generalization of endoscopic technology and screening, clinical application of magnetically controlled capsule gastroscopy (MCCG) has been increasing. In recent years, various types of MCCG are used globally. Therefore, establishing relevant guidelines on MCCG is of great significance. The current guidelines containing 23 statements were established based on clinical evidence and expert opinions, mainly focus on aspects including definition and diagnostic accuracy, application population, technical optimization, inspection process, and quality control of MCCG. The level of evidence and strength of recommendations were evaluated. The guidelines are expected to guide the standardized application and scientific innovation of MCCG for the reference of clinicians.

Colon capsule retention in a patient with large bowel stenosis due to diverticulosis - a case report

Capsule retention is a rare complication to capsule endoscopy. It is often asymptomatic and resolves itself spontaneously. In some cases, endoscopy or surgery is necessary to remove the capsule. Cases of capsule retention in the colon are not reported very often and precautions in subsequent investigations must be considered. We present a case of a 74-year-old woman who underwent colon capsule endoscopy (CCE) due to a positive fecal immunochemical test. The CCE was incomplete, and the patient was referred to conventional colonoscopy, which was complicated by perforation of the large bowel during the procedure. This lead to a CT scan showing the capsule proximal to a stenotic colon segment which was subsequently surgically removed. In patients who report lack of capsule excretion and stenosis is not verified, colonoscopy can be carried out, but with caution.

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.

Modified method of patency judgement using patency capsule prior to capsule endoscopy in clinical practice

In 2012, Japan approved the use of a tag-less patency capsule (PC), which evaluates gastrointestinal patency before small-bowel capsule endoscopy (SBCE). This study aimed to evaluate the validity of our modification on the passage criteria for this PC in clinical practice. We retrospectively enrolled 326 consecutive patients who underwent PC examination before SBCE. If X-ray could not reveal the PC in the body during the judgement time (30–33 h after ingestion), we defined it as ‘estimated patency’ and performed SBCE. We employed plain computed tomography (CT) for the second judgement, as needed. The overall patency rate was 95.1%. By X-ray, 41 (12.6%) patients were judged to have ‘estimated patency’, and SBCE could be safely performed. Plain CT judgement was necessary in 106 patients (32.5%). One PC case had a residual coating film associated with stenosis in a patient with Crohn’s disease (CD), and one (0.3%) SBCE case had capsule retention resulting from false CT judgement. Multivariate analysis revealed that established CD and inpatient were factors related to no-patency. In conclusion, PC is useful for examining gastrointestinal patency, keeping in mind CT misjudgement. If PC was not found in the body via X-ray, performing SBCE as ‘estimated patency’ seemed appropriate.

Video Capsule Endoscopy after Bariatric Surgery: A Tertiary Referral Center Experience

BACKGROUND AND AIM

Minimal data are available regarding the performance of video capsule endoscopy (VCE) in patients who underwent bariatric surgery. We aimed to report indications, feasibility, and safety of VCE performed after bariatric surgery, specifically focusing on diagnosis rates of Crohn's disease (CD) in this population.

METHODS

A retrospective analysis of all VCE procedures was performed between January 2015 and December 2019. All patients who underwent bariatric surgery prior to VCE were included. Indication for VCE, ingestion methods, completion rates, retention rates, and endoscopic findings were recorded.

RESULTS

A total of 1,255 patients underwent VCE examination during the study period, of which 31 (2.5%) underwent bariatric surgery prior to VCE. The most common bariatric surgery was laparoscopic sleeve gastrectomy (16 patients, 51.6%), and the most common indication for VCE was evaluation of iron deficiency anemia (14 patients, 45.1%). The majority of patients ingested the capsule independently, without endoscopic assistance (20, 64.5%). Although a patency capsule was not used in our cohort, no events of capsule retention were documented. Mean transit time was 4.32 h. Only 4 events of incomplete examination were recorded. Over a median follow-up of 27.5 months (IQR 13.0-34.2), 10 patients (31.2%) had a final diagnosis of CD with a median Lewis score of 225 (IQR 135-900).

CONCLUSION

VCE is a feasible and safe procedure after bariatric surgery. Oral ingestion does not carry risk of retention. It is an effective means of diagnosis of small-bowel CD in this population.

Efficacy and safety of vibrating capsule for functional constipation (VICONS): A randomised, double-blind, placebo-controlled, multicenter trial

BACKGROUND

Functional constipation (FC) is an intractable disease that carries large financial burden as well as emotional and physical stress. We aimed to assess the efficacy and safety of the newly developed smartphone-controlled vibrating capsule (VC) in patients with FC.

METHODS

From December 2018 to February 2020, we did a multicenter, blinded, placebo-controlled randomised trial in six top general hospitals in China focusing on patients aged 18 to 80 with FC. Patients were randomly assigned in a 1:1 ratio to receive VCs or placebo treatment for six weeks (two capsules per week) after a two-week baseline period. The primary outcome was the responder rate, defined as the proportion of patients with an increase of at least one complete spontaneous bowel movement (CSBM) per week during treatment compared to baseline in the full analysis set. This trial is registered with ClinicalTrials.gov, number NCT04671264, and is completed.

FINDINGS

107 patients aged from 18 to 74 were randomly assigned to receive VC (n = 53) or placebo treatment (n = 54). The responder rate in the VC group was significantly higher than that in the placebo group (64·2% vs. 35·8%; difference, 27·7% [95% CI, 10·4-45·1]; P = 0·005). More patients in the VC group reported weekly CSBMs ≥ 1 for at least four weeks during treatment (difference, 22·7% [95% CI, 8-46]; P = 0·022) and follow-up period (difference, 17.3% [95% CI, 0-35]; P = 0·048). The mean Patient Assessment of Constipation-Symptoms score and Patient Assessment of Constipation-Quality of Life score differed significantly from the baseline in both groups (all P < 0·0001). The most common adverse event associated with VC was abdominal discomfort (3·7%).

INTERPRETATION

VCs can promote defecation, as well as ameliorating symptoms and improving the quality of life in patients with FC with sustained efficacy. VC appears to be a potential alternative physical treatment for FC with the exact mechanism and parameters warranting further investigation.

FUNDING

The study was supported by "One hundred leading scientists for 21st century" of Health Department of Shanghai Municipal Government (to ZL, No.2017BR005).

Assessment of Capsule Endoscopy Utilizing Capsocam Plus in Patients With Suspected Small Bowel Disease Including Pilot Study With Remote Access Patients During Pandemic

Background

CapsoCam Plus is a capsule endoscopy (CE) system that utilizes four cameras to capture a panoramic view. This has theoretical advantage over conventional forward-viewing CE with limited field of view. Its ease of administration without requiring any additional equipment during the recording also provides a unique opportunity for patients to self-administer the test. We aimed to evaluate real-life experience using this novel system and to determine feasibility of a remote access program.

Methods

Retrospective chart review was conducted for consecutive adult outpatients who underwent CE using CapsoCam Plus. Patients with significant challenges for in-person procedures were selected for remote access through mail courier services. Gastric transit time, small bowel transit time, completion rate, diagnostic yield and adverse events were compared between remote access versus usual practice.

Results

Ninety-four patients (52.1% male) were included, with 28 in remote access program. Most common indication was gastrointestinal bleeding (85.1%). Complete examination was achieved in 87 patients. Five (5.3%) patients’ capsule remained in stomach during the recording, while two (2.1%) patients missed capsule retrieval. Median small bowel and gastric transit times were 231.9 (interquartile range [IQR] 169.5–308.2) and 27.6 (IQR 13.8–63.5) minutes, respectively. Diagnostic yield was 23.4%. There was no difference in completion rate or transit times between two groups, but diagnostic yield was higher in remote access group (odds ratio 3.80, 95% confidence interval 1.28–11.31). One patient required elective endoscopic retrieval of capsule.

Conclusion

CapsoCam Plus can be safely administered remotely with a high degree of success, which may facilitate timely investigations while limiting nonessential physical interactions during pandemic.

Capsule Endoscopy in Inflammatory Bowel Disease: When? To Whom?

Capsule endoscopy (CE) has proven to be a valuable diagnostic modality for small bowel diseases over the past 20 years, particularly Crohn's disease (CD), which can affect the entire gastrointestinal tract from the mouth to the anus. CE is not only used for the diagnosis of patients with suspected small bowel CD, but can also be used to assess disease activity, treat-to-target, and postoperative recurrence in patients with established small bowel CD. As CE can detect even mildly non-specific small bowel lesions, a high diagnostic yield is not necessarily indicative of high diagnostic accuracy. Moreover, the cost effectiveness of CE as a third diagnostic test employed usually after ileocolonoscopy and MR or CT enterography is an important consideration. Recently, new developments in colon capsule endoscopy (CCE) have increased the utility of CE in patients with ulcerative colitis (UC) and pan-enteric CD. Although deflation of the colon during the examination and the inability to evaluate dysplasia-associated lesion or mass results in an inherent risk of overestimation or underestimation, the convenience of CCE examination and the risk of flare-up after colonoscopy suggest that CCE could be used more actively in patients with UC.

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.

Ingestible devices for studying the gastrointestinal physiology and their application in oral biopharmaceutics

Ingestible sensor systems are unique tools for obtaining physiological data from an undisturbed gastrointestinal tract. Since their dimensions correspond to monolithic oral dosage forms, such as enteric coated tablets or hydrogel matrix tablets, they also allow insights into the physiological conditions experienced by non-disintegrating dosage forms on their way through the gastrointestinal tract. In this work, the different ingestible sensor systems which can be used for this purpose are described and their potential applications as well as difficulties and pitfalls with respect to their use are presented. It is also highlighted how the data on transit times, pH, temperature and pressure as well as the data from different animal models commonly used in drug product development such as dogs and pigs have contributed to a deeper mechanistic understanding of oral drug delivery.

Risk of bleeding following double balloon enteroscopy in patients on continued antiplatelet and/or anticoagulation therapy

Background and study aims  Anticoagulation (AC) and antiplatelet (AP) therapy may increase the risk of gastrointestinal bleeding after double balloon enteroscopy (DBE); however, limited data are currently available regarding the incidence. The aim of this study was to assess the incidence and clinical characteristics of post-DBE bleeding in patients on AC and AP therapy. Patients and methods  The medical records of patients who underwent DBE between 2009 and 2013 at Mayo Clinic, Florida, were retrospectively reviewed. Patients were divided into three groups: 1) continued AP therapy; 2) AC therapy; and 3) neither AP nor AC at the time of DBE. Follow-up data were collected at 60 days and 1 year. Results  A total of 683 patients were identified; 43 on AC, 183 on AP and 457 not on AP or AC therapy. The most common indication for DBE was obscure gastrointestinal bleeding in the groups on and not on AP (85.3 % vs 70.9 %, P  < 0.0001). There was no statistical difference in post-DBE bleeding rates in patients on AP vs not on AP at 60 days (11.5 % vs 7.5 %, P  = 0.12) or 1 year (19.9 % vs 15.7 %, P  = 0.23). Rates of bleeding in patients on AC were 11.6 % within 60 days and 22.5 % within 1 year. Multivariate analysis reflected American Society of Anesthesiologist > 3 and indication for DBE of GI bleeding were independent risk factors for post-DBE bleeding within 1 year. Conclusions  Continued antiplatelet use at the time of DBE was not an independent risk factor for bleeding post-DBE at 60 days or 1 year of follow up.

Capsule retention caused by cryptogenic multifocal ulcerous stenosing enteritis

INTRODUCTION

cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare illness. Capsule retention (CR) has been reported in a few cases of CMUSE.

METHODS

we present four cases of CMUSE with CR. None of the patients showed any symptoms or signs of small bowel obstruction before capsule endoscopy (CE). All patients denied a history of non-steroidal anti-inflammatory drugs intake, radiotherapy treatment or abdominal surgery.

RESULTS

CE disclosed circumferential stenosis with or without ulcers in the small bowel, some accompanied by mucosal edema, white spots and nodules. All patients underwent an elective surgery to remove the retained capsule and resect the lesions.

CONCLUSION

CE plays a positive role in diagnosing CMUSE. CE findings are as important as CR to alert about the diagnosis of CMUSE.

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.

Endorobots for Colonoscopy: Design Challenges and Available Technologies

Colorectal cancer (CRC) is the second most common cause of cancer death worldwide, after lung cancer (Sung et al., 2021). Early stage detection is key to increase the survival rate. Colonoscopy remains to be the gold standard procedure due to its dual capability to optically inspect the entire colonic mucosa and to perform interventional procedures at the same time. However, this causes pain and discomfort, whereby it requires sedation or anaesthesia of the patient. It is a difficult procedure to perform that can cause damage to the colonic wall in some cases. Development of new technologies aims to overcome the current limitations on colonoscopy by using advancements in endorobotics research. The design of these advanced medical devices is challenging because of the limited space of the lumen, the contorted shape, and the long tract of the large bowel. The force applied to the colonic wall needs to be controlled to avoid collateral effects such as injuries to the colonic mucosa and pain during the procedure. This article discusses the current challenges in the colonoscopy procedure, the available locomotion technologies for endorobots used in colonoscopy at a prototype level and the commercial products available.

A Descriptive Analysis of Capsule Endoscopy Events in the FDA Manufacturer and User Facility Device Experience (MAUDE) Database

Introduction

The malfunction of capsule endoscopy (CE) devices is a significant reason for the failure of CE procedures, which could hinder and prevent diagnosis. Unfortunately, malfunction-related adverse events (AEs) caused by CE devices are rarely reported in publications. Although most malfunction-related AEs could not lead to physical harm, they could reduce the efficiency of medical care and increase medical costs. The manufacturer and user facility device experience (MAUDE) database, a publicly accessible resource for patient safety, contains not only the common complications of CE but also valuable malfunction-related AEs, which have been underutilized. Therefore, the study aims to discover and analyze the possible AEs associated with CE and demonstrate the utility of the MAUDE reports to promote patient safety.

Materials and Methods

We acquired MAUDE reports of CE systems from January 01, 2008, to July 31, 2020, through a systematic search strategy. We utilized the manufacturers, brand names, and product codes as search terms from which medical device reports including structured data and narrative texts were extracted, followed by a manual review of the narrative texts, reporter occupation, device involved, event type and the phase of the event; finally, patient outcomes were recorded and analyzed as per CE categories and characteristics.

Results

A total of 377 CEs medical device reports were retrieved, and 342 reports were included after reviewing. There were 327 mandatory reports (96%) and 15 voluntary reports (4%). These reports referred to capsule endoscope (n = 213), sensing system (n = 66), patency capsule (n = 38), and capsule delivery device (n = 26). A total of 349 CE-related AEs were identified, including complications (n = 228), malfunction-related AEs (n = 109), and other events (n = 12). The composition of AEs was not the same for the CE devices. Complications were major AEs of capsule endoscope and patency capsule, but malfunction-related AEs were the most common in AEs of sensing systems and capsule delivery devices.

Conclusion

MAUDE serves as an invaluable data source for investigating malfunction-related AEs. In addition to common complications, malfunction of CE devices could threaten patient safety in CE procedures. Improving awareness of the malfunction of CE devices and raising adequate training for staff working in gastrointestinal (GI) endoscopic units could be critical and beneficial in preventing malfunction-related AEs.

The Detective Value of Magnetically Controlled Robotic Capsule Endoscopy in Patients With Suspected Small Intestinal Disease

Objective: To explore the detective value of magnetically controlled robotic capsule endoscopy (MCRCE) in patients with suspected small intestinal disease.

Patients and Methods: In total, 1,802 patients with suspected small intestinal disease and negative gastroenteroscopy from Shanghai Jiao Tong University Affiliated Sixth People's Hospital were examined with MCRCE, and the data were collected for further analysis.

Results: Among the 1,802 patients who were examined with MCRCE, 974 were diagnosed with small intestinal disease, reaching a positive detection rate of 54.1%. The five most common conditions that were detected include non-specific enteritis in 722 cases (40.1%), small intestinal ulcers in 87 cases (4.8%), abnormal small bowel evacuation in 45 cases (2.5%), small intestinal bleeding in 33 cases (1.8%), and small intestinal yellow spots in 31 cases (1.7%). The running time of the capsules in the small intestine ranged from 85–437 min, with an average of 210.24 ± 89.08 min. No complications, such as intestinal obstruction or capsule retention, were observed in all patients.

Conclusion: MCRCE is a safe and non-invasive endoscopic examination with a highly accurate detection rate for small intestinal diseases.

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.

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

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

Role of Capsule Endoscopy in Inflammatory Bowel Disease

In Crohn disease (CD), the use of capsule endoscopy (CE) for suspected versus established disease is very different. Most patients with CD are diagnosed with ileocolonoscopy. In patients with a negative ileocolonoscopy, CE is the next best test in suspected CD. In patients with established CD, the potential benefits of CE are rating severity of disease, establishing extent and distribution, and following mucosal healing in a treat to target strategy. In those with proximal small bowel disease, CE can help in diagnosis and prognostication. In ulcerative colitis, CE has a limited role, but that may change with evolving technology.

Colon Capsule Endoscopy vs. CT Colonography Following Incomplete Colonoscopy: A Systematic Review with Meta-Analysis

Following incomplete colonoscopy (IC) patients often undergo computed tomography colonography (CTC), but colon capsule endoscopy (CCE) may be an alternative. We compared the completion rate, sensitivity and diagnostic yield for polyp detection from CCE and CTC following IC. A systematic literature search resulted in twenty-six studies. Extracted data included inter alia, complete/incomplete investigations and polyp findings. Pooled estimates of completion rates of CCE and CTC and complete colonic view rates (CCE reaching the most proximal point of IC) of CCE were calculated. Per patient diagnostic yields of CCE and CTC were calculated stratified by polyp sizes. CCE completion rate and complete colonic view rate were 76% (CI 95% 68-84%) and 90% (CI 95% 83-95%). CTC completion rate was 98% (CI 95% 96-100%). Diagnostic yields of CTC and CCE were 10% (CI 95% 7-15%) and 37% (CI 95% 30-43%) for any size, 13% (CI 95% 9-18%) and 21% (CI 95% 12-32%) for >5-mm and 4% (CI 95% 2-7%) and 9% (CI 95% 3-17%) for >9-mm polyps. No study performed a reference standard follow-up after CCE/CTC in individuals without findings, rendering sensitivity calculations unfeasible. The increased diagnostic yield of CCE could outweigh its slightly lower complete colonic view rate compared to the superior CTC completion rate. Hence, CCE following IC appears feasible for an introduction to clinical practice. Therefore, randomized studies investigating CCE and/or CTC following incomplete colonoscopy with a golden standard reference for the entire population enabling estimates for sensitivity and specificity are needed.

Predictors for Small Bowel Stenosis in Balloon-Assisted Enteroscopy

BACKGROUND

Predictors besides symptoms of obstruction indicating small bowel stenosis are little known.

AIMS

To detect predictors of small bowel stenosis in balloon-assisted enteroscopy.

METHODS

Over a 6-year period, 461 patients had enteroscopy for suspected small intestinal disease. Details of clinical manifestations, medical history, demographic characteristics, findings of examinations, information on enteroscopy, and treatment were retrospectively collected based on medical records. Small bowel stenosis was defined as stricture that over-tube cannot go through in enteroscopy. Univariate and multivariate analyses were performed to identify predictors for small bowel stenosis.

RESULTS

A total of 314 patients had definite diagnosis after enteroscopy, imaging modalities, and/or even surgical exploration. They were included in this study for analyses. Mean age for them was 48.2 years old (range 15-81 years). Small bowel stenosis was present in 59 patients (18.8%). Analyses showed that CT/MRI indicating stenosis was significantly associated with severe stenosis (p = 0.014) but insignificant related to general stenosis (p = 0.097). Predictive factors that accompanied stenosis were age ≥ 60 years (OR = 2.1, 95% CI 1.1-4.0), underweight (BMI ≤ 18.5) (OR = 3.4, 95% CI 1.4-8.4), symptoms of obstruction (OR = 3.6, 95% CI 1.8-7.4), and overt small bowel bleeding (OR = 0.5, 95% CI 0.2-0.9).

CONCLUSIONS

Small bowel stenosis more tended to occur to patients with symptoms of obstruction, no overt small bowel bleeding, age ≥ 60 years, or underweight.

Sending in the ViCE Squad: Evaluation and Management of Patients with Small Intestinal Bleeding

Bleeding from the small intestine remains a clinically challenging diagnostic and therapeutic problem. It may be minor, requiring only supplemental iron treatment, to patients who have severe overt bleeding that requires multimodal intervention. This article provides an up-to-date review of the state-of-the-art of diagnosis and treatment of small intestinal bleeding.

Colon capsule endoscopy

There are multiple indications for luminal imaging of the colon. From assessment of known disease, to diagnosing new pathology; intra-luminal visualisation is the mainstay of gastrointestinal diagnosis. Colonoscopy and radiological imaging are currently the most frequently deployed diagnostic methods. However, both have an associated risk profile, have significant resource pressures and are not universally tolerated. Colon capsule endoscopy (CCE) offers an adjunct to these diagnostic options. In this narrative review the utility of CCE is described. Its current uses, potential benefits and future developments are also discussed.

Double-balloon enteroscopy for retrieving retained small-bowel video capsule endoscopes: a systematic review

Background and aim: Capsule retention is the most common adverse event associated with video capsule endoscopy. The use of double-balloon enteroscopy-assisted capsule endoscope retrieval has been increasingly reported in recent years. However, evidence is limited regarding its success rate, associated factors, and subsequent clinical outcomes.Methods: A systematic review of relevant studies published before January 2019 was performed. Successful retrieval rate and associated factors, rate of endoscopic balloon dilation, and outcomes after double-balloon enteroscopy were summarized and pooled.Results: Within 154 associated original articles, 12 including 150 cases of capsule retrieval by double-balloon enteroscopy were included. The estimated pooled successful retrieval rate was 86.5% (95% confidence interval, 75.6-95.1%). Anterograde approach and capsules retained in the jejunum or trapped by malignant strictures were associated with a higher successful retrieval rate than the retrograde approach (62/83 [74.7%] vs. 10/38 [26.3%], p < .001) and capsules retained in the ileum (41/41 [100.0%] vs. 43/58 [74.1%], p < .001) or trapped by benign strictures (21/21 [100.0%] vs. 65/83 [78.3%], p = .043). Endoscopic balloon dilation was performed in 38.8% (95% confidence interval, 22.3-56.3%) of patients with benign strictures. Two perforations (1.3%) were reported as severe adverse events after double-balloon enteroscopy. A significantly lower surgery rate was found among cases with successful video capsule removal compared with unsuccessful cases (7.2% vs. 38.5%, p = .002).Conclusions: Double-balloon enteroscopy is feasible and safe for removing retained video capsule endoscopes, and its use could decrease the need for surgery in patients with benign strictures and facilitate subsequent surgery in patients with malignant strictures.

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.

Endoscopy in inflammatory bowel disease: from guidelines to real life

Endoscopy has a central role in the management of inflammatory bowel disease (IBD), providing crucial data for diagnostic and therapeutic decisions, treating disease-related complications, and assisting in the early detection of dysplasia and prevention of colorectal cancer in the setting of IBD. Treatment targets have significantly shifted in IBD, focusing on achieving mucosal healing, a more meaningful endpoint than clinical remission. With the emergence of novel therapies, we aim to alter the course of the disease and prevent irreversible damage to the bowel. To that end, obtaining reliable and reproducible assessments of endoscopic disease activity has become an issue of great importance. Although several guidelines include recommendations regarding endoscopic surveillance in patients with long-standing IBD, there is an open debate regarding the best examination method and the appropriate follow-up intervals. Another important issue is whether surveillance guidelines are actually implemented in real-life practice and what is the preferred surveillance method among endoscopists. Significant changes have occurred in the endoscopic world with the development of new diagnostic and therapeutic modalities and their incorporation in everyday practice. We aimed to assess the real-life application of guideline recommendations regarding endoscopy in IBD patients and to review newly emerged data which might impact these recommendations in the near future.

Adherence to European Society of Gastrointestinal Endoscopy recommendations of endoscopists performing small bowel capsule endoscopy in Italy

BACKGROUND

The European Society of Gastrointestinal Endoscopy (ESGE) has recently issued a technical review focused on small bowel capsule endoscopy (SBCE).

AIM

To compare SBCE current practice in Italy to ESGE technical recommendations.

MATERIAL AND METHODS

A dedicated per-centre semi-quantitative questionnaire was prepared by a group of SBCE experts. One-hundred-fifty Centres were invited to participate in the data collection concerning SBCEs performed between June 2016 and June 2017. Data were compared with ESGE recommendations.

RESULTS

120 Centres participated in the data collection. Current practices agreed with ESGE recommendations in 56.3% (9/16) of the issues evaluated. Differences between ESGE recommendations and current practice concerned the management of patients with pacemakers or cardiac implantable defibrillators (which was in agreement with ESGE recommendations in 31.7% and 15.8% of Centres, respectively), the SBCE setting (only 51% of SBCEs were performed as outpatients procedures), the assessment of capsule excretion (timing and modality were in agreement with ESGE recommendation in 20.0% of Centres), and in the involvement of trained nurses or fellows in training as pre-readers (7/120; 5.8%).

CONCLUSIONS

Although SBCE is widely used and largely available in Italy, there are still some technical, practical and organizational issues that can be modified to bridge the gap between current practice and ESGE guideline recommendations.

Clinical application of magnetically controlled capsule gastroscopy in gastric disease diagnosis: recent advances

Magnetically controlled capsule gastroscopy (MCCG) is a novel system primarily used for the diagnosis of gastric disease. It consists of an endoscopic capsule with magnetic material inside, external guidance magnet equipment, data recorder and computer workstation. Several clinical trials have demonstrated that MCCG is comparable in accuracy in diagnosing gastric focal disease when compared to conventional gastroscopy. Further clinical studies are needed to test the diagnostic accuracy and improve the functioning of MCCG. This novel MCCG system could be a promising alternative for screening for gastric diseases, with the advantages of no anesthesia required, comfort and high acceptance across populations.

Efficacy of capsule endoscopy in patients with cirrhosis for the diagnosis of upper gastrointestinal lesions and small bowel abnormalities: a study protocol for prospective interventional study

INTRODUCTION AND AIMS

The role of capsule endoscopy (CE) in patients with liver cirrhosis (LC) has yet to be established; however, it is likely that it will remain a valuable diagnostic modality in several groups of patients with LC. The primary aims of the current prospective interventional study are to examine the prevalence for small bowel lesions and transit time of CE in the gastrointestinal tract in patients with LC with oesophageal varices (EVs) requiring endoscopic therapies.

METHODS AND ANALYSIS

The current study will be a single-centre prospective interventional study. Our study participants are LC subjects with portal hypertension who were determined to be necessary for prophylactic endoscopic therapies for EVs. From the view point of safety, patients with gastrointestinal obstruction or fistula or those being suspected of having gastrointestinal obstruction or fistula will be excluded from our study. Patients with implanted medical devices will be also excluded. CE will be performed prior to prophylactic endoscopic therapies in the same hospitalisation and relevant images will be analysed after 8 hours by expert endoscopists. This study will continue to recruit until 50 participants.

ETHICS AND DISSEMINATION

This study has received approval from the Institutional Review Board at Hyogo College of Medicine (approval no. 2680). The study protocol, informed assent form and other submitted files were reviewed and acknowledged. Final data will be publicly scattered regardless of the study results. A report releasing study results will be submitted for publication in a suitable journal after being finished in data collection.

TRIAL REGISTRATION NUMBER

UMIN000028433 (https://upload.umin.ac.jp/).