Diagnostic yield of small bowel capsule endoscopy depends on the small bowel transit time

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic yield of inpatient capsule endoscopy

Background

Capsule endoscopy (CE) provides a novel approach to evaluate obscure gastrointestinal bleeding. Yet CE is not routinely utilized in the inpatient setting for a variety of reasons. We sought to identify factors that predict complete CE and diagnostically meaningful CE, as well as assess the impact of inpatient CE on further hospital management.1 na d2

Methods

We conducted a retrospective review of patients undergoing inpatient CE at a tertiary referral, academic center over a 3 year period. We analyzed data on patient demographics, medical history, endoscopic procedures, hospital course, and results of CE. The primary outcome was complete CE and the secondary outcome was positive findings of pathology on CE.

Results

131 patients were included (56.5% were men 43.5% women, median age of 71.0 years). Overall, CE was complete in 77.1% of patients. Complete CE was not related to motility risk factors, gender, or administration modality. Patients with incomplete CE tended to be older, have lower BMI, and Caucasian, however results did not reach statistical significance (p = 0.06; p = 0.06; p = 0.08 respectively). Positive CE was noted in 73.3% of patients, with 35.1% of all patients having active bleeding. Positive CE was not associated with AVM risk factors or medication use. 28.0% of patients underwent subsequent hospital procedures, among which 67.6% identified the same pathology seen on CE.

Conclusions

Contrary to previous studies, we found the majority of inpatient CEs were complete and positive for pathology. We found high rates of correlation between CE and subsequent procedures. The use of CE in the inpatient setting helps to guide the diagnosis and treatment of hospitalized patients with obscure gastrointestinal bleeding.

Video capsule endoscopy in patients with iron deficiency anaemia: experience at a regional Australian service

OBJECTIVE

The objective of this study was to identify the diagnostic performance of video capsule endoscopy (VCE) among patients presenting with iron deficiency anaemia (IDA) and negative bidirectional endoscopy to a gasteroendoscopy practice in regional Australia. The secondary objectives were to identify the distribution of findings and factors predictive of positive findings in a regional setting.

RESULTS

In total 123 procedures were included in the study. Mean age of the patients was 67.9 years. Females made up 60.2% (n = 74) of the study population. Mean haemoglobin and ferritin levels were 93.3 g/L and 11.9 ug/L, respectively. Positive findings were present in 67 procedures (54.5%) with the most frequent finding being small bowel angiodysplasia (53.7%, n = 36/67), followed by ulceration/significant erosion (26.8%, n = 18/67), fresh blood (20.8%, n = 14/67) and tumour/polyp (16.4%, n = 11/67). Haemoglobin level was the only variable associated with positive findings (p = 0.005) in the study population. Of the procedures reporting positive findings outside the small bowel, the majority (80%) were within reach of conventional upper endoscopy and may have implications for future practice, particularly when allocating health resources in a rural setting.

Value of the diving method for capsule endoscopy in the examination of small-intestinal disease: a prospective randomized controlled trial

BACKGROUND AND AIMS

Video capsule endoscopy (VCE) is limited by poor image quality and incomplete small-bowel transit. This study was designed to evaluate the diving method for VCE in the examination of small-intestinal disease.

METHODS

From July 2017 to September 2017, eligible patients were randomly assigned to 2 groups, the diving group and the control group. For the diving group, 500 mL of water was administered every hour when the capsule reached the small bowel. The primary outcomes were image quality and positive findings. Secondary outcomes were the completion rate of examination, gastric transit time (GTT), small-bowel transit time (SBTT), lesion detection rate, adverse events, and patient satisfaction.

RESULTS

One hundred forty patients were included. The scores of endoscopic images in the proximal third and middle third of the small bowel in the diving group were significantly higher than that in the control group (3.47 ± .60 vs 3.11 ± .63 [P = .007] and 3.24 ± .59 vs 2.78 ± .74 [P = .002], respectively). The positive findings in the distal third of the small bowel were significantly different between the 2 groups (P = .005). The completion rate in the diving group was significantly higher (92.19% vs 76.32%, respectively; P = .012). The GTT, SBTT, and lesion detection rate were similar in 2 groups (P = .282, .067, and .577, respectively). No discomfort or adverse events were reported except for a few cases of frequent urination.

CONCLUSIONS

The diving method for VCE examination effectively improves the endoscopic view in the proximal and middle thirds of the small bowel and the positive findings in the distal small intestine and increases the completion rate. (Clinical trial registration number: ChiCTR-RDR-17011823.).

Training, Reading, and Reporting for Small Bowel Video Capsule Endoscopy

Video capsule endoscopy (VCE) is an established modality for examining the small bowel. Formal training in interpretation and reporting of VCE examinations, along with assessment of performance metrics, is advocated for all gastroenterology fellowship programs. This review provides an overview of VCE minimum training requirements and competency assessment, cognitive and technical aspects of interpretation, and standardized reporting of findings. In order to optimize and advance the clinical utility of VCE, efforts must continue to promote and encourage consensus and standardization of training, definition and assessment of competence, enhancements of VCE reading tools, and use of appropriate nomenclature in VCE reports.

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

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

Artificial intelligence that determines the clinical significance of capsule endoscopy images can increase the efficiency of reading

Artificial intelligence (AI), which has demonstrated outstanding achievements in image recognition, can be useful for the tedious capsule endoscopy (CE) reading. We aimed to develop a practical AI-based method that can identify various types of lesions and tried to evaluate the effectiveness of the method under clinical settings. A total of 203,244 CE images were collected from multiple centers selected considering the regional distribution. The AI based on the Inception-Resnet-V2 model was trained with images that were classified into two categories according to their clinical significance. The performance of AI was evaluated with a comparative test involving two groups of reviewers with different experiences. The AI summarized 67,008 (31.89%) images with a probability of more than 0.8 for containing lesions in 210,100 frames of 20 selected CE videos. Using the AI-assisted reading model, reviewers in both the groups exhibited increased lesion detection rates compared to those achieved using the conventional reading model (experts; 34.3%–73.0%; p = 0.029, trainees; 24.7%–53.1%; p = 0.029). The improved result for trainees was comparable to that for the experts (p = 0.057). Further, the AI-assisted reading model significantly shortened the reading time for trainees (1621.0–746.8 min; p = 0.029). Thus, we have developed an AI-assisted reading model that can detect various lesions and can successfully summarize CE images according to clinical significance. The assistance rendered by AI can increase the lesion detection rates of reviewers. Especially, trainees could improve their efficiency of reading as a result of reduced reading time using the AI-assisted model.

Clinical features of capsule endoscopy in 825 children: A single-center, retrospective cohort study

Video capsule endoscopy (VCE) can detect mucosal lesions in the intestine, especially in the small bowel.Our study aims to evaluate the applications of VCE for pediatric gastrointestinal diseases.In this retrospective study, we included all patients who underwent VCE between December 2012 and December 2018. Clinical information and VCE data were analyzed.Among 828 patients, the completion rate was 99.6% (n = 825), with an average age of 10.2 ± 3.3 years old. A total of 459 VCE procedures showed abnormalities, and the overall diagnostic yield was 55.6%. The most common indications for VCE were abdominal pain among 505 (61.2%) patients and hematochezia (10.1%) among 83. Among the positive results of VCE, small bowel ulcers accounted for the highest percentage (57.7%), of which 164 cases were diagnosed as inflammatory bowel disease. For obscure gastrointestinal bleeding, 12 cases were diagnosed as Meckel's diverticulum. In terms of the small bowel transit time of VCE, compared with the negative group [288 (216.5, 390.3) min] and the enteritis group [277 (192.5, 374.8) min], a longer transit time was needed in the small bowel ulcer group [332.5 (240, 451.5) min, P < .01]. There were no correlations of positive VCE findings with anemia, the white blood cell count, the C-reactive protein level or the small bowel transit time according to Spearman rank analysis.VCE is relatively well tolerated and safe in children and has great value for the diagnosis and treatment of abdominal pain, especially inflammatory bowel disease and obscure gastrointestinal bleeding.

Simplify to improve in capsule endoscopy - TOP 100 is a swift and reliable evaluation tool for the small bowel inflammatory activity in Crohn's disease

Background: Capsule endoscopy is a widely recognized method to study the small bowel, including in patients with Crohn's disease (CD). The Lewis score (LS) is a valuable tool in this setting, able to assess inflammatory activity. TOP100, a new software tool of the RAPID Reader^®, emerged to assist in the time-consuming capsule reading process, by automatically selecting 100 images that will most likely contain abnormalities.Aim: Evaluate the agreement between TOP100 and classic reading (CR) in determining LS in the setting of CD.Methods: Retrospective study including consecutive patients undergoing small bowel capsule endoscopy (SBCE) for suspected or established CD. One experienced reader performed CR and calculated the LS. Another experienced reader, blinded to the CR results, reviewed all SBCE videos using TOP100 and calculated the LS.Results: One hundred and fifteen patients were included. SBCE detected significant inflammatory activity (LS ≥135) in 64 patients (55.7%). We verified a strong agreement between the two methods of capsule reading (Kappa = 0.83, p < .001), with an agreement on 89.6% of the cases. The agreement was superior in moderate-to-severe inflammatory activity (Kappa = 0.92, p < .001). All cases of moderate-to-severe activity detected by CR were identified by TOP100 as significant inflammatory activity. A good agreement was verified in all tertiles (p < .001).Conclusions: Although the classical review of the entire video remains the gold standard, the TOP100 has been shown to be a useful tool in assisting the reader in a prompt calculation of LS, in particular for identifying patients with moderate-to-severe inflammatory disease.

Bowel preparation for small bowel capsule endoscopy - The later, the better!

BACKGROUND

In small bowel capsule endoscopy (SBCE), the presence of residue may compromise diagnostic accuracy.

AIMS

To assess differences in quality of visualisation and diagnostic yield of SBCE using 3 different preparation protocols.

METHODS

Prospective, randomized, blind, pilot study. Protocol A:Clear liquids diet the day before the examination with fasting from 8p.m.; Protocol B:Protocol A + 2 pouches of Moviprep^®(polyethylene glycol electrolyte solution + sodium ascorbate) in 1 L of water from 8p.m. of the day before the examination; Protocol C: Protocol A + 2 pouches of Moviprep^® in 1 L of water consumed after real-time confirmation of capsule arrival at small bowel. Small bowel preparation was classified by two experienced physicians, considering the percentage of the examination during which mucosal observation was adequate: Excellent(>90%); Good(90-75%); Fair(75-50%); Poor(<50%).

RESULTS

101 patients randomized to the 3 protocols (A 37, B 31, C 33 patients). Protocol C had an excellent/good small bowel preparation in a higher percentage of examinations for both readers(Reader 1-A:37.8% vs B:45.2% vs C:78.8%, p = 0.002 and Reader 2 -A:37.8% vs B:41.9% vs C:75.8%, p = 0.003). Also, protocol C had a higher detection of angioectasia (A:5.4% vs B:9.7% vs C:27.3%, p = 0.022).

CONCLUSIONS

The administration of Moviprep^® after the capsule had reached the small bowel was associated with a better small bowel preparation and a higher detection of angioectasia.

Influence of demographic and clinical features of the patient on transit times and impact the on the diagnostic yield of capsule endoscopy

BACKGROUND

transit times in the gastric cavity and the small bowel can be easily calculated using capsule endoscopy software. The factors that can influence these times and impact on diagnostic yield have not been completely assessed.

AIMS

to analyze the influence of demographic and clinical features on transit times and the impact on diagnostic yield.

METHODS

a retrospective, single-center study of examinations between January 2013 and November 2017 was performed. The analyzed features included gender, age, body mass index, diabetes, thyroid disease and indications. The association and correlation between the variables were assessed, as well as the presence of positive and significant findings.

RESULTS

six hundred and thirty-one patients were included in the study. Gastric and small bowel transit times were 36.10 ± 48.50 and 251.82 ± 116.42 minutes, respectively. Gastric time was not affected by any of the variables. Small bowel time was longer in males, patients over 60 years of age and diabetics. Prolonged small bowel time, male gender and older age were associated with a higher diagnostic yield. Age over 60 years was the only factor independently associated with positive findings (OR: 1.550 [1.369-1.754]; p: 0.007).

CONCLUSIONS

patients over 60 years have a longer small bowel transit time and higher probability of having small bowel lesions. Males and diabetic patients also seem more likely to have longer transit times and higher rates of positive findings.

Capsule endoscopy with PillCamSB2 versus PillCamSB3: has the improvement in technology resulted in a step forward?

AIM

To compare the findings and completion rate of PillCam® SB2 and SB3.

METHODS

This was a retrospective single-center study that included 357 consecutive small bowel capsule endoscopies (SBCE), 173 SB2 and 184 SB3. The data collected included age, gender, capsule type (PillCam® SB2 or SB3), quality of bowel preparation, completion of the examination, gastric and small bowel transit time, small bowel findings, findings in segments other than the small bowel and the detection of specific anatomical markers, such as the Z line and papilla.

RESULTS

The mean age of the patients was 48 years and 66.9% were female. The two main indications were suspicion/staging of inflammatory bowel disease (IBD) and obscure gastrointestinal bleeding (OGIB) (43.7% and 40.3%, respectively). Endoscopic findings were reported in 76.2% of examinations and 53.5% were relevant findings. No significant differences were found between SB2 and SB3 with regard to completion rate (93.6% vs 96.2%, p = 0.27), overall endoscopic findings (73.4% vs 78.8%, p = 0.23), relevant findings (54.3% vs 52.7%, p = 0.76), first tertile findings (43.9% vs 48.9%, p = 0.35), extra-SB findings (23.7% vs 17.3%, p = 0.14), Z line and papilla detection rate (35.9% vs 35.7%, p = 0.97 and 27.1% vs 32.6%, p = 0.32, respectively). With regard to the patient subgroups with suspicion/staging of IBD, significant differences were found in relation to the detection of villous edema and the 3rd tertile findings, thus favoring SB3 (26.3% vs 43.8%, p = 0.02 and 47.4% vs 66.3%, p = 0.02, respectively). Mucosal atrophy was significantly more frequently diagnosed with the PillCam® SB3 in patients with anemia/OGIB (0% vs 8%, p = 0.03).

CONCLUSIONS

Overall, PillCam® SB3 did not improve the diagnostic yield compared to SB2, although it improved the detection of villous atrophy and segmental edema.

IMPACT OF SMALL BOWEL CAPSULE ENDOSCOPY IN IRON DEFICIENCY ANEMIA: INFLUENCE OF PATIENT’SAGE ON DIAGNOSTIC YIELD

ABSTRACT BACKGROUND: Iron deficiency anemia remains one of the main indications to perform small bowel capsule endoscopy. Literature suggests that diagnostic yield is influenced by patient’s age but with conflicting results regarding age cutoff. OBJECTIVE: We aimed to clarify the differences in diagnostic yield and incidence of specific findings according to age. METHODS: Retrospective single-center study including 118 patients performing small bowel capsule endoscopy in the study of iron deficiency anemia. Videos were reviewed and small bowel findings that may account for anemia were reported. Incomplete examinations were excluded. Findings were compared between patients ≤60 and >60 years. RESULTS: Patients had a mean age of 58 years old (SD ±17.9) with 69.5% females (n=82). The overall diagnostic yield was 49% (58/118), being higher among patients >60 years (36/60, diagnostic yield 60%) than those ≤60 years (20/58, diagnostic yield 34%), (P<0.01). Angioectasias were more frequent in patients >60 years (45% vs 9%, P<0.01). Patients ≤60 years presented more frequently significant inflammation (Lewis score >135 in 10.3% vs 1.7%, P<0.05) and other non-vascular lesions (24% vs 10%, P=0.04). CONCLUSION: In our cohort small bowel capsule endoscopy diagnosed clinically relevant findings in the setting of iron deficiency anemia in almost half the patients. Diagnostic yield was higher in patients older than 60 years (60%), with vascular lesions being more frequent in this age group. Despite the lower diagnostic yield in patients ≤60 years, significant pathology was also found in this age group, mainly of inflammatory type.

Video capsule endoscopy is safe and effective in suspected small bowel bleeding among left ventricular assist device recipients

Introduction:

Suspected small bowel bleeding is frequently encountered in left ventricular assist device recipients and the identification of the culprit lesion may be challenging. Data regarding the safety and yield of small bowel capsule in the investigation of suspected small bowel bleeding are limited. We aimed to evaluate the safety and efficacy of small bowel video capsule endoscopy for the investigation of suspected small bowel bleeding among left ventricular assist device recipients.

Methods:

Patients with left ventricular assist device who underwent video capsule endoscopy for the investigation of suspected small bowel bleeding were identified. Suspected small bowel bleeding was defined as the presence of overt bleeding at least 30 days following left ventricular assist device implantation with no identifiable cause in upper and lower endoscopy.

Results:

A total of 10 patients with left ventricular assist device associated suspected small bowel bleeding performed 12 small bowel capsule endoscopies between January 2008 and December 2015 at our tertiary medical care facility. There were no cases of capsule retention or any other serious adverse events during the exams. A significant finding was identified in 8 out of 10 patients, including 3 cases of small bowel angioectasia, 2 cases of small bowel ulcers, 1 case of cecal polyp, and 2 cases of active bleeding with no apparent bleeding source. Small bowel enteroscopy identified and treated bleeding angioectasia in the latter two cases.

Conclusion:

Small bowel capsule endoscopy is safe and effective in the investigation of left ventricular assist device associated suspected small bowel bleeding.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Implications of small-bowel transit time in the detection rate of capsule endoscopy: A multivariable multicenter study of patients with obscure gastrointestinal bleeding

AIM

To define the role of small-bowel transit time in the detection rate of significant small-bowel lesions.

METHODS

Small-bowel capsule endoscopy records, prospectively collected from 30 participating centers in the Lombardy Registry from October 2011 to December 2013, were included in the study if the clinical indication was obscure gastrointestinal bleeding and the capsule reached the cecum. Based on capsule findings, we created two groups: P2 (significant findings) and P0-1 (normal/negligible findings). Groups were compared for age, gender, small-bowel transit time, type of instrument, modality of capsule performance (outpatients vs inpatients), bowel cleanliness, and center volume.

RESULTS

We retrieved and scrutinized 1,433 out of 2,295 capsule endoscopy records (62.4%) fulfilling the inclusion criteria. Patients were 67 ± 15 years old, and 815 (57%) were males. In comparison with patients in the P0-1 group, those in the P2 group (n = 776, 54%) were older (P < 0.0001), had a longer small-bowel transit time (P = 0.0015), and were more frequently examined in low-volume centers (P < 0.001). Age and small-bowel transit time were correlated (P < 0.001), with age as the sole independent predictor on multivariable analysis. Findings of the P2 group were artero-venous malformations (54.5%), inflammatory (23.6%) and protruding (10.4%) lesions, and luminal blood (11.5%).

CONCLUSION

In this selected, prospectively collected cohort of small-bowel capsule endoscopy performed for obscure gastrointestinal bleeding, a longer small-bowel transit time was associated with a higher detection rate of significant lesions, along with age and a low center volume, with age serving as an independent predictor.

The Effect of Prucalopride on Small Bowel Transit Time in Hospitalized Patients Undergoing Capsule Endoscopy

BACKGROUND

The inpatient status is a well-known risk factor for incomplete video capsule endoscopy (VCE) examinations due to prolonged transit time. We aimed to evaluate the effect of prucalopride on small bowel transit time for hospitalized patients undergoing VCE.

METHODS

We included all hospitalized patients who underwent VCE at a tertiary academic center from October 2011 through September 2016. A single 2 mg dose of prucalopride was given exclusively for all patients who underwent VCE between March 2014 and December 2015. VCE studies were excluded if the capsule was retained or endoscopically placed, if other prokinetic agents were given, in cases with technical failure, or if patients had prior gastric or small bowel resection.

RESULTS

442 VCE were identified, of which 68 were performed in hospitalized patients. 54 inpatients were included, of which 29 consecutive patients received prucalopride. The prucalopride group had a significantly shorter small bowel transit time compared to the control group (92 versus 275.5, p < 0.001). There was a trend for a higher completion rate in the prucalopride group (93.1% versus 76%, p = 0.12).

CONCLUSIONS

Our results suggest that the administration of prucalopride prior to VCE is a simple and effective intervention to decrease small bowel transit time.

Video Capsule Endoscopy: A Tool for the Assessment of Small Bowel Transit Time

Purpose

Video capsule endoscopy (VCE) is a procedure that uses a wireless camera to take pictures of the gastrointestinal (GI) tract. A wireless motility capsule (WMC) of a similar size has been developed, which measures pH, pressure, and temperature and can be used to assess regional and total GI transit times. VCE could also potentially be used as a tool for measuring small bowel transit time (SBTT).

Methods

This study was designed to obtain SBTT from VCE and compare it with historical data generated by WMC. Gastric transit time (GTT) was also measured. Patients were included if the indication for VCE was either iron deficiency anemia (IDA) or overt obscure GI bleed (OOGIB), and they did not have any known motility disorder. Results from VCE were also compared in diabetic vs. non-diabetic patients.

Results

There were a total of 147 VCE studies performed, including 42 for OOGIB and 105 for IDA. Median GTT and SBTT were 0.3 and 3.6 h, respectively. The overall median GTT and SBTT were 0.3 and 3.6 h, respectively, in the IDA group compared with 0.3 and 3.4 h in the OOGIB group. When compared with WMC, the GTT and SBTT were significantly faster in both groups (GTT: 3.6 h and SBTT: 4.6 h). The median GTT and SBTT were not significantly different in diabetics vs. non-diabetics [GTT: 17.5 vs. 18.0 min (P = 0.86) and SBTT: 3.9 h (237 min) vs. 3.8 h (230 min), respectively (P = 0.90)].

Conclusion

SBTT as measured using VCE is not significantly different in OOGIB compared with IDA. Both GTT and SBTT are significantly faster as assessed by VCE, which is initiated in the fasting state, compared with WMC measurement, which is initiated after a standard meal. In summary, VCE could potentially be used for measuring SBTT in the fasting state.

A trial of the use of patency capsules in combination with overnight capsule endoscopy

BACKGROUND

The PillCam® patency capsule (PPC) was developed to minimize the risk of capsule retention during capsule endoscopy (CE). Typically, the use of patency capsules prior to CE requires patients to be monitored over a period of time. To reduce the need for frequent outpatient visits during PPC examination and CE, we developed the overnight CE (ON-CE) procedure.

METHODS

Between October 2012 and January 2014, a total of 19 patients (15 males and 4 females, mean age 48.4 years) were administered PPC to assess the patency of the small intestine prior to ON-CE at JA Onomichi General Hospital in Hiroshima, Japan.

RESULTS

PPC confirmed patency of the small intestine in 15 of the 19 patients. Of these 15 patients, 14 proceeded to ON-CE. The CE was cancelled in 1 patient and the cecal intubation time exceeded 8 h in another patient. For the remaining 12 patients, the mean small intestine observation coverage was 92.3% and the mean cecal intubation time was 325 min. There were no adverse events and the discharge of the capsule was confirmed in all cases.

CONCLUSION

When patency of the gastrointestinal tract was confirmed with the PPC, ON-CE was performed safely and effectively.

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

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

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

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

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

The use of domperidone increases the completion rate of small bowel capsule endoscopy: does this come at the expense of diagnostic yield?

BACKGROUND

The completion rate (CR) of small bowel capsule endoscopy (SBCE) has been reported at 81.3% to 84.8%. Prokinetic agents are used to increase CR and (theoretically) diagnostic yield (DY). Domperidone has not been widely used in SBCE; unlike metoclopramide, it lacks extrapyramidal adverse effects.

OBJECTIVES

This was a retrospective study. This study aimed to assess gastric transit time (GTT), small bowel transit time (SBTT), and the CR of SBCE when using domperidone. Furthermore, we aimed to compare the CR of 2 different SBCE systems (MiroCam, PillCam). Consecutive SBCE examinations (January 2008 to October 2012) from a tertiary referral center were analyzed.

RESULTS

In the aforementioned period, a total of 635 SBCE examinations were performed: 379/635 (59.7%) with PillCamSB and 256 (40.3%) with MiroCam. In 437/635 (68.8%) examinations, liquid domperidone (5 mg) was administered for capsule ingestion, whereas 198 (31.2%) ingested the capsule without any domperidone. Although the 2 groups were comparable, the median age of patients who received domperidone was higher compared with patients who did not receive (58 vs. 48 y, P=0.027). In our cohort, the overall CR of SBCE was 88.9%. The 2 SBCE systems showed equivalent CR (PillCamSB 88.9%, MiroCam 89.1%; P =0.96). The use of liquid domperidone increased CR (91.1% vs. 84.3%; P =0.042). Interestingly, the use of domperidone with PillCamSB was associated with reduced DY for vascular, inflammatory, and polyps/mass-type lesions. This effect was not seen in the MiroCam group. Furthermore, the median GTT and the median SBTT did not differ between the 2 groups (GTT/SBTT with domperidone 26.0'/221.0' and without 29.0'/228.0', respectively; P=0.461/P=0.477). A higher CR was noted when domperidone was used with PillCamSB (93.0% vs. 89.5%, P=0.012) than with MiroCam (84.4% vs. 83.3%, P=0.08).

LIMITATIONS

The major limitations of this study were the retrospective design of the study and limited numbers on MiroCam with no domperidone.

CONCLUSIONS

In conclusion, the use of domperidone increases the CR of SBCE with PillCamSB. However, this increase does not translate into higher DY. A smart, tailored approach, which may include domperidone, purgatives, and real-time viewers, may be used in the clinical practice to improve DY until technology delivering capsules with much longer battery time becomes available.

Re-bleeding events in patients with obscure gastrointestinal bleeding after negative capsule endoscopy

AIM: To investigate long-term re-bleeding events after a negative capsule endoscopy in patients with obscure gastrointestinal bleeding (OGIB) and the risk factors associated with the procedure.

METHODS: Patients referred to Hospital Egas Moniz (Lisboa, Portugal) between January 2006 and October 2012 with OGIB and a negative capsule endoscopy were retrospectively analyzed. The following study variables were included: demographic data, comorbidities, bleeding-related drug use, hemoglobin level, indication for capsule endoscopy, post procedure details, work-up and follow-up. Re-bleeding rates and associated factors were assessed using a Cox proportional hazard analysis. The Kaplan-Meier method was used to estimate the cumulative incidence of re-bleeding at 1, 3 and 5 years, and the differences between factors were evaluated.

RESULTS: The study population consisted of 640 patients referred for OGIB investigation. Wireless capsule endoscopy was deemed negative in 113 patients (17.7%). A total of 64.6% of the population was female, and the median age was 69 years. The median follow-up was forty-eight months (interquartile range 24-60). Re-bleeding occurred in 27.4% of the cases. The median time to re-bleeding was fifteen months (interquartile range 2-33). In 22.6% (n = 7) of the population, small-bowel angiodysplasia was identified as the culprit lesion. A univariate analysis showed that age > 65 years old, chronic kidney disease, aortic stenosis, anticoagulant use and overt OGIB were risk factors for re-bleeding; however, on a multivariate analysis, there were no risk factors for re-bleeding. The cumulative risk of re-bleeding at 1, 3 and 5 years of follow-up was 12.9%, 25.6% and 31.5%, respectively. Patients who presented with overt OGIB tended to re-bleed sooner (median time for re-bleeding: 8.5 mo vs 22 mo).

CONCLUSION: Patients with OGIB despite a negative capsule endoscopy have a significant re-bleeding risk; therefore, these patients require an extended follow-up strategy.

Practical aspects of delivering a small bowel endoscopy service in the UK

Capsule endoscopy remains at the forefront of small bowel investigation, offering the only non-invasive means of directly imaging the mucosa of the small bowel. Recommended for the investigation of obscure gastrointestinal bleeding, Crohn's disease, coeliac disease, small bowel tumours and hereditary polyposis syndromes, the uptake of small bowel capsule endoscopy has been widespread in the UK. However, despite a wealth of published literature supporting the utility of capsule endoscopy in clinical practice, there are limited data regarding the actual practical aspects of service delivery, training and quality assurance. In this article, we attempt to address this by considering specific factors that contribute to provision of a high-quality capsule service. The role of formal training, accreditation and quality assurance measures is also discussed.

Effect of longer battery life on small bowel capsule endoscopy

AIM: To determine if longer battery life improves capsule endoscopy (CE) completion rates.

METHODS: A retrospective study was performed at a tertiary, university-affiliated hospital in Vancouver, Canada. Patients who underwent CE with either PillCam™ SB2 or SB2U between 01/2010 and 12/2013 were considered for inclusion. SB2 and SB2U share identical physical dimensions but differ in their battery lives (8 h vs 12 h). Exclusion criteria included history of gastric or small bowel surgery, endoscopic placement of CE, interrupted view of major landmarks due to technical difficulty or significant amount of debris, and repeat CE using same system. Basic demographics, comorbidities, medications, baseline bowel habits, and previous surgeries were reviewed. Timing of major landmarks in CE were recorded, and used to calculate gastric transit time, small bowel transit time, and total recording time. A complete CE study was defined as visualization of cecum. Transit times and completion rates were compared.

RESULTS: Four hundred and eight patients, including 208 (51.0%) males, were included for analysis. The mean age was 55.5 ± 19.3 years. The most common indication for CE was gastrointestinal bleeding (n = 254, 62.3%), followed by inflammatory bowel disease (n = 86, 21.1%). There was no difference in gastric transit times (group difference 0.90, 95%CI: 0.72-1.13, P = 0.352) and small bowel transit times (group difference 1.07, 95%CI: 0.95-1.19, P = 0.261) between SB2U and SB2, but total recording time was about 14% longer in the SB2U group (95%CI: 10%-18%, P < 0.001) and there was a corresponding trend toward higher completion rate (88.2% vs 93.2%, OR = 1.78, 95%CI 0.88-3.63, P = 0.111). There was no statistically significant difference in the rates of positive findings (OR = 0.98, 95%CI: 0.64-1.51, P = 0.918).

CONCLUSION: Extending the operating time of CE may be a simple method to improve completion rate although it does not affect the rate of positive findings.

Application of wireless power transmission systems in wireless capsule endoscopy: an overview

Wireless capsule endoscopy (WCE) is a promising technology for direct diagnosis of the entire small bowel to detect lethal diseases, including cancer and obscure gastrointestinal bleeding (OGIB). To improve the quality of diagnosis, some vital specifications of WCE such as image resolution, frame rate and working time need to be improved. Additionally, future multi-functioning robotic capsule endoscopy (RCE) units may utilize advanced features such as active system control over capsule motion, drug delivery systems, semi-surgical tools and biopsy. However, the inclusion of the above advanced features demands additional power that make conventional power source methods impractical. In this regards, wireless power transmission (WPT) system has received attention among researchers to overcome this problem. Systematic reviews on techniques of using WPT for WCE are limited, especially when involving the recent technological advancements. This paper aims to fill that gap by providing a systematic review with emphasis on the aspects related to the amount of transmitted power, the power transmission efficiency, the system stability and patient safety. It is noted that, thus far the development of WPT system for this WCE application is still in initial stage and there is room for improvements, especially involving system efficiency, stability, and the patient safety aspects.

Small bowel bleeding: a comprehensive review

The small intestine is an uncommon site of gastro-intestinal (GI) bleeding; however it is the commonest cause of obscure GI bleeding. It may require multiple blood transfusions, diagnostic procedures and repeated hospitalizations. Angiodysplasia is the commonest cause of obscure GI bleeding, particularly in the elderly. Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients. Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds. Deep enteroscopy has also an added advantage of therapeutic potential. Computed tomography is helpful in identifying extra-intestinal lesions. In cases of difficult diagnosis, surgery and intra-operative enteroscopy can help with diagnosis and management. The treatment is dependent upon the aetiology of the bleed. An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy. Small bowel bleeding can be managed by conservative, radiological, pharmacological, endoscopic and surgical methods, depending upon indications, expertise and availability. Some patients, especially those with multiple vascular lesions, can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.

High sensitivity of quick view capsule endoscopy for detection of small bowel Crohn's disease

BACKGROUND AND AIM

Capsule endoscopy (CE) has a high sensitivity for diagnosing small bowel Crohn's disease, but video analysis is time-consuming. The quick view (qv) function is an effective tool to reduce time consumption. The aim of this study was to determine the rate of missed small bowel ulcerations with qv-CE compared with standard view and the diagnostic accuracy of qv-CE in suspected Crohn's disease.

METHODS

This study consisted of two parts: (i) 12 small bowel segments with Crohn's disease of varying severity were selected for a detailed analysis of the number and type of lesions visualized with CE and qv-CE, and (ii) a blinded study of the diagnostic accuracy of qv-CE including 40 patients with suspected Crohn's disease. Ileocolonoscopy and CE served as gold standard.

RESULTS

Part 1: CE visualized 171 ulcerations compared with 102 detected with qv-CE (miss rate 40%, P = 0.02). Part 2: qv-CE identified 15 of 16 patients with small bowel Crohn's disease corresponding to a 94% sensitivity, and overall, 39 out of 40 patients were classified correct (diagnostic accuracy 98%). Qv-CE was false negative in one patient because of a leap of 3 min and 20 s in the terminal ileum. Reading times varied from 5 to 18 min (median 10).

CONCLUSION

Despite a significant number of missed lesions, qv-CE is a safe and time-reducing method for diagnosing small bowel Crohn's disease. To avoid false negative cases, we recommend viewing the terminal ileum in standard view.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Small bowel carcinoid: Location isn’t everything!

AIM: To investigate the prognostic significance of the primary site of disease for small bowel carcinoid (SBC) using a population-based analysis.

METHODS: The Surveillance, Epidemiology and End Results (SEER) database was queried for histologically confirmed SBC between the years 1988 and 2009. Overall survival (OS) and disease-specific survival (DSS) were analyzed using the Kaplan-Meier method and compared using Log rank testing. Log rank and multivariate Cox regression analyses were used to identify predictors of survival using age, year of diagnosis, race, gender, tumor histology/size/location, tumor-node-metastasis stage, number of lymph nodes (LNs) examined and percent of LNs with metastases.

RESULTS: Of the 3763 patients, 51.2% were male with a mean age of 62.13 years. Median follow-up was 50 mo. The 10-year OS and DSS for duodenal primaries were significantly better when compared to jejunal and ileal primaries (P = 0.02 and < 0.0001, respectively). On multivariate Cox regression analysis, after adjusting for multiple factors, primary site location was not a significant predictor of survival (P = 0.752 for OS and P = 0.966 DSS) while age, number of primaries, number of LNs examined, T-stage and M-stage were independent predictors of survival.

CONCLUSION: This 21-year, population-based study of SBC challenges the concept that location of the primary lesion alone is a significant predictor of survival.

Small-bowel capsule endoscopy: a ten-point contemporary review

The introduction of capsule endoscopy (CE) in clinical practice increased the interest for the study of the small-bowel. Consequently, in about 10 years, an impressive quantity of literature on indications, diagnostic yield (DY), safety profile and technical evolution of CE has been published as well as several reviews. At present time, there are 5 small-bowel capsule enteroscopy (SBCE) models in the worldwide market. Head-to-head trials have showed in the great majority of studies comparable results in terms of DY, image quality and completion rate. CE meta-analyses formed the basis of national/international guidelines; these guidelines place CE in a prime position for the diagnostic work-up of patients with obscure gastrointestinal bleeding, known and/or suspected Crohn's disease and possible small-bowel neoplasia. A 2-L polyethylene glycol-based purge, administered the day before the procedure, is the most widely practiced preparation regimen. Whether this regimen can be further improved (i.e., by further decreasing its volume, changing the timing of administration, coupling it with prokinetics and/or other factors) or if it can really affect the DY, is still under discussion. Faecal calprotectin has been used in SBCE studies in two settings: in patients taking non-steroidal anti-inflammatory drugs, to evaluate the type and extent of mucosal damage and, more importantly from a clinical point of view, in patients with known or suspected Crohn's disease for assessment of inflammation activity. Although there is still a lot of debate around the exact reasons of SBCE poor performance in various small-bowel segments, it is worth to remember that the capsule progress is non-steerable, hence more rapid in the proximal than in lower segments of the small-bowel. Capsule aspiration, a relatively unexpected complication, has been reported with increasing frequency. This is probably related with the increase in the mean age of patients undergoing CE. CE video review is a time-consuming procedure. Therefore, several attempts have been made to develop technical software features, in order to make CE video analysis easier and shorter (without jeopardizing its accuracy). Suspected Blood Indicator, QuickView and Fujinon Intelligent Chromo Endoscopy are some of the software tools that have been checked in various clinical studies to date.

Evaluation of small bowel bleeding

PURPOSE OF REVIEW

The review focuses on the latest techniques that are evolving in the management of small bowel bleeding.

RECENT FINDINGS

Video capsule endoscopy has the highest yield of diagnosis when it is performed within 48 h of the bleeding event (78 versus 48%). The pooled detection rate of double balloon endoscopy was noted to be 68.1% for obscure gastrointestinal bleeding according to a systematic review of 66 studies in the last 10 years. Also a recent review, which focused on analysis of 68 studies found that the procedural characteristics were comparable for double balloon, single balloon and spiral enteroscopy though the procedure time was fastest for the spiral enteroscopy group. Medical therapy for vascular lesions is in its infancy but shows promise.

SUMMARY

Advanced diagnostic and therapeutic endoscopic techniques are changing the paradigm of care for patients with small bowel bleeding.

Inpatient capsule endoscopy leads to frequent incomplete small bowel examinations

AIM: To examine the predictive factors of capsule endoscopy (CE) completion rate (CECR) including the effect of inpatient and outpatient status.

METHODS: We identified 355 consecutive patients who completed CE at Rush University Medical Center between March 2003 and October 2005. Subjects for CE had either nothing by mouth or clear liquids for the afternoon and evening of the day before the procedure. CE exams were reviewed by two physicians who were unaware of the study hypotheses. After retrospective analysis, 21 cases were excluded due to capsule malfunction, prior gastric surgery, endoscopic capsule placement or insufficient data. Of the remaining 334 exams [264 out-patient (OP), 70 in-patient (IP)], CE indications, findings, location of the patients [IP vs OP and intensive care unit (ICU) vs general medical floor (GMF)] and gastrointestinal transit times were analyzed. Statistical analysis was completed using SPSS version 17 (Chicago, IL). Chi-square, t test or fisher exact-tests were used as appropriate. Multivariate logistic regression analysis was used to identify variables associated with incomplete CE exams.

RESULTS: The mean age for the entire study population was 54.7 years. Sixty-one percent of the study population was female, and gender was not different between IPs vs OPs (P = 0.07). The overall incomplete CECR was 14% in our study. Overt obscure gastrointestinal bleeding (OGB) was a significantly more common indication for the IP CE (P = 0.0001), while abdominal pain and assessment of IBD were more frequent indications for the OP CE exams (P = 0.002 and P = 0.01, respectively). Occult OGB was the most common indication and arteriovenous malformations were the most common finding both in the IPs and OPs. The capsule did not enter the small bowel (SB) in 6/70 IPs and 8/264 OPs (P = 0.04). The capsule never reached the cecum in 31.4% (22/70) of IP vs 9.5% (25/ 264) of OP examinations (P < 0.001). The mean gastric transit time (GTT) was delayed in IPs compared to OPs, 98.5 ± 139.5 min vs 60.4 ± 92.6 min (P = 0.008). Minimal SB transit time was significantly prolonged in the IP compared to the OP setting [IP = 275.1 ± 111.6 min vs OP = 244.0 ± 104.3 min (P = 0.037)]. CECR was also significantly higher in the subgroup of patients with OGB who had OP vs IP exams (95% vs 80% respectively, P = 0.001). The proportion of patients with incomplete exams was higher in the ICU (n = 7/13, 54%) as compared to the GMF (n = 15/57, 26%) (P = 0.05). There was only a single permanent SB retention case which was secondary to a previously unknown SB stricture, and the remaining incomplete SB exams were due to slow transit. Medications which affect gastrointestinal system motility were tested both individually and also in aggregate in univariate analysis in hospitalized patients (ICU and GMF) and were not predictive of incomplete capsule passage (P > 0.05). Patient location (IP vs OP) and GTT were independent predictors of incomplete CE exams (P < 0.001 and P = 0.008, respectively).

CONCLUSION: Incomplete CE is a multifactorial problem. Patient location and related factors such as severity of illness and sedentary status may contribute to incomplete exams.

Three-dimensional image reconstruction in capsule endoscopy

To date, limited research has been carried out in developing methods and materials that offer three-dimensional (3-D) representation of the digestive tract. In the field of capsule endoscopy (CE), hardware approaches have been developed that provide real time both 3-D information and texture using an infrared projector and a complementary metal oxide semiconductor camera. The major drawbacks of this system are its size, power consumption and packaging issues. A software approach to approximate a 3-D representation of digestive tract surface utilising current CE technology has been proposed. The algorithm utilizes the Shape from Shading technique and seem to provide promising results for polypoid structures and angioectasias. Further clinical evaluation is currently under way.