PillCam Colon 2 capsule in patients unable or unwilling to undergo colonoscopy

Colon Capsule Endoscopy in the Diagnosis of Colon Polyps: Who Needs a Colonoscopy?

Colon screening programs have reduced colon cancer mortality. Population screening should be minimally invasive, safe, acceptably sensitive, cost-effective, and scalable. The range of screening modalities include guaiac or immunochemical fecal occult blood testing and CT colonography and colonoscopy. A number of carefully controlled studies concur that second-generation capsule endoscopy has excellent sensitivity for polyp detection and a high negative predictive value. Colon capsules fulfill the screening expectation of safety, high sensitivity for polyp detection, and patient acceptance, and appear to straddle the divide between occult blood testing and colonoscopy. While meeting these criteria, there remains the challenges of scaling, capsule practitioner training, resource allocation, and implementing change of practice. Like CT colonography, capsule screening presents the clinician with a decision on the threshold for colonoscopy referral. Overall, colon capsules are an invaluable tool in polyp detection and colon screening and offer a filter that determines “who needs a colonoscopy?”.

Panintestinal capsule endoscopy in patients with celiac disease

INTRODUCTION

Capsule endoscopy has proven its utility in diagnosing villous atrophy and lymphoma in patients with celiac disease. Recently, a novel capsule endoscopy system was introduced which enables the examination of the small and large bowel. So far, it has not been evaluated in patients with celiac disease.

OBJECTIVE

The primary objective of this study was to evaluate the novel panintestinal capsule endoscopy system in patients with celiac disease.

METHODS

Eleven patients with histologically proven celiac disease (Marsh 0-IV), who underwent a panintestinal capsule endoscopy between March 2018 and April 2019 at our institution, were included in this retrospective single-center study. All patients performed standard bowel preparation prior to the examination. Diagnostic yield, safety and therapeutic impact were analyzed. In addition, the correlation between capsule endoscopy findings and the histology of the duodenal mucosa was assessed.

RESULTS

Panintestinal capsule endoscopy was feasible and produced an acceptable visualization quality in all cases. Concordance of capsule endoscopy findings with the Marsh classification showed a good correlation (r = 0.8). No lymphomas were detected. Evaluation of the colon revealed diminutive polyps (median size 4 mm) in 18% of patients.

CONCLUSIONS

The novel panintestinal capsule endoscopy system shows a fair correlation with the Marsh classification in patients with celiac disease. It is also capable of identifying colon polyps. Therefore, the novel panintestinal capsule endoscopy system can be considered for patients with celiac disease and an indication for capsule endoscopy.

Diagnostic Yields and Clinical Impacts of Capsule Endoscopy

Observing the entire small bowel is difficult due to the presence of complex loops and a long length. Capsule endoscopy (CE) provides a noninvasive and patient-friendly method for visualizing the small bowel and colon. Small bowel capsule endoscopy (SBCE) has a critical role in the diagnosis of small bowel disorders through the direct observation of the entire small bowel mucosa and is becoming the primary diagnostic tool for small bowel diseases. Recently, colon capsule endoscopy (CCE) was also considered safe and feasible for obtaining sufficient colonic images in patients with incomplete colonoscopy, in the absence of bowel obstruction. This review article assesses the current status of CE in terms of the diagnostic yield and the clinical impact of SBCE in patients with obscure gastrointestinal bleeding, who have known or suspected Crohn's disease, small bowel tumor and inherited polyposis syndrome, celiac disease, and those who have undergone CCE.

Scoring Systems for Clinical Colon Capsule Endoscopy-All You Need to Know

In the constantly developing era of minimal diagnostic invasiveness, the role of colon capsule endoscopy in colonic examination is being increasingly recognised, especially in the context of curtailed endoscopy services due to the COVID-19 pandemic. It is a safe diagnostic tool with low adverse event rates. As with other endoscopic modalities, various colon capsule endoscopy scores allow the standardisation of reporting and reproducibility. As bowel cleanliness affects CCE’s diagnostic yield, a few operator-dependent scores (Leighton–Rex and CC-CLEAR scores) and a computer-dependent score (CAC score) have been developed to grade bowel cleanliness objectively. CCE can be used to monitor IBD mucosal disease activity through the UCEIS and the panenteric CECDAIic score for UC and CD, respectively. CCE may also have a role in CRC screening, given similar sensitivity and specificity rates to conventional colonoscopy to detect colonic polyps ≥ 10 mm and CRC. Given CCE’s diagnostic yield and reproducible clinical scores with high inter-observer agreements, CCE is fast becoming a suitable alternative to conventional colonoscopy in specific patient populations.

The Entire Intestinal Tract Surveillance Using Capsule Endoscopy after Immune Checkpoint Inhibitor Administration: A Prospective Observational Study

BACKGROUND

Despite the proven efficacy of immune checkpoint inhibitors (ICIs) against various types of malignancies, they have been found to induce immune-related adverse events, such as enterocolitis; however, the clinical features of ICI-induced enterocolitis remain to be sufficiently elucidated, which is significant, considering the importance of early detection in the appropriate management and treatment of ICI-induced enterocolitis. Therefore, the current study aimed to determine the utility of capsule endoscopy as a screening tool for ICI-induced enterocolitis.

METHODS

This single-center, prospective, observational study was conducted on patients with malignancy who received any ICI between April 2016 and July 2020 at Keio University Hospital. Next, second-generation capsule endoscopy (CCE-2) was performed on day 60 after ICI initiation to explore the entire gastrointestinal tract.

RESULTS

Among the 30 patients enrolled herein, 23 underwent CCE-2. Accordingly, a total of 23 findings were observed in 14 (60.8%) patients at any portion of the gastrointestinal tract (7 patients in the colon, 4 patients in the small intestine, 2 patients in both the colon and the small intestine, and 1 patient in the stomach). After capsule endoscopy, 2 patients (8.7%) developed ICI-induced enterocolitis: both had significantly higher Capsule Scoring of Ulcerative Colitis than those who had not developed ICI-induced enterocolitis (p = 0.0455). No adverse events related to CCE-2 were observed.

CONCLUSIONS

CCE-2 might be a safe and useful entire intestinal tract screening method for the early detection of ICI-induced enterocolitis in patients with malignancies.

Imaging alternatives to colonoscopy: CT colonography and colon capsule. European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline - Update 2020

1: ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia.Strong recommendation, high quality evidence.ESGE/ESGAR do not recommend barium enema in this setting.Strong recommendation, high quality evidence. 2: ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. The timing depends on an interdisciplinary decision including endoscopic and radiological factors.Strong recommendation, low quality evidence.ESGE/ESGAR suggests that, in centers with expertise in and availability of colon capsule endoscopy (CCE), CCE preferably the same or the next day may be considered if colonoscopy is incomplete.Weak recommendation, low quality evidence. 3: When colonoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with alarm symptoms.Strong recommendation, high quality evidence.Because of lack of direct evidence, ESGE/ESGAR do not recommend CCE in this situation.Very low quality evidence.ESGE/ESGAR recommend CTC as an acceptable alternative to colonoscopy for patients with non-alarm symptoms.Strong recommendation, high quality evidence.In centers with availability, ESGE/ESGAR suggests that CCE may be considered in patients with non-alarm symptoms.Weak recommendation, low quality evidence. 4: Where there is no organized fecal immunochemical test (FIT)-based population colorectal screening program, ESGE/ESGAR recommend CTC as an option for colorectal cancer screening, providing the screenee is adequately informed about test characteristics, benefits, and risks, and depending on local service- and patient-related factors.Strong recommendation, high quality evidence.ESGE/ESGAR do not suggest CCE as a first-line screening test for colorectal cancer.Weak recommendation, low quality evidence. 5: ESGE/ESGAR recommend CTC in the case of a positive fecal occult blood test (FOBT) or FIT with incomplete or unfeasible colonoscopy, within organized population screening programs.Strong recommendation, moderate quality evidence.ESGE/ESGAR also suggest the use of CCE in this setting based on availability.Weak recommendation, moderate quality evidence. 6: ESGE/ESGAR suggest CTC with intravenous contrast medium injection for surveillance after curative-intent resection of colorectal cancer only in patients in whom colonoscopy is contraindicated or unfeasibleWeak recommendation, low quality evidence.There is insufficient evidence to recommend CCE in this setting.Very low quality evidence. 7: ESGE/ESGAR suggest CTC in patients with high risk polyps undergoing surveillance after polypectomy only when colonoscopy is unfeasible.Weak recommendation, low quality evidence.There is insufficient evidence to recommend CCE in post-polypectomy surveillance.Very low quality evidence. 8: ESGE/ESGAR recommend against CTC in patients with acute colonic inflammation and in those who have recently undergone colorectal surgery, pending a multidisciplinary evaluation.Strong recommendation, low quality evidence. 9: ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥ 6 mm detected at CTC or CCE.Follow-up CTC may be clinically considered for 6 - 9-mm CTC-detected lesions if patients do not undergo polypectomy because of patient choice, comorbidity, and/or low risk profile for advanced neoplasia.Strong recommendation, moderate quality evidence.

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.

Colon capsule endoscopy versus CT colonography after incomplete colonoscopy. Application of artificial intelligence algorithms to identify complete colonic investigations

BACKGROUND

Guidelines suggest computed tomography colonography (CTC) following incomplete optical colonoscopy (OC). Colon capsule endoscopies (CCE) have been suggested as an alternative, although completion rates have been unsatisfactory. Introduction of artificial intelligence (AI)-based localization algorithms of the camera capsules may enable identification of incomplete CCE investigations overlapping with incomplete OCs.

OBJECTIVE

The study aims to investigate relative sensitivity of CCE compared with CTC following incomplete OC, investigate the completion rate when combining results from the incomplete OC and CCE, and develop a forward-tracking algorithm ensuring a safe completeness of combined investigations.

METHODS

In this prospective paired study, patients with indication for CTC following incomplete OC were included for CCE and CTC. Location of CCE abortion and OC abortion were registered to identify complete combined investigations. AI-based algorithm for localization of capsules were developed reconstructing the passage of the colon.

RESULTS

In 237 individuals with CTC indication; 105 were included, of which 97 underwent both a CCE and CTC. CCE was complete in 66 (68%). Including CCEs which reached most oral point of incomplete OC, 73 (75%) had complete colonic investigations; 78 (80%) had conclusive investigations. Relative sensitivity of CCE compared with CTC was 2.67 (95% confidence interval (CI) 1.76;4.04) for polyps >5 mm and 1.91 (95% CI 1.18;3.09) for polyps >9 mm. An AI-based algorithm was developed.

CONCLUSION

Sensitivity of CCE following incomplete OC was superior to CTC. Introducing and improving algorithm-based localization of capsule abortion may increase identification of overall complete investigation rates following incomplete OC.ClinicalTrials.gov identifier: NCT02826993.

Booster medication to achieve capsule excretion in colon capsule endoscopy: a randomized controlled trial of three regimens

Background and study aims  To achieve a complete colon capsule endoscopy, the entire colon must be visualized, clean and filled with clear fluids. The primary aim was to compare three booster regimens in colon capsule endoscopy in achieving capsule excretion within recording time. Secondary aims were quality of bowel cleansing and completion rate (both adequate cleansing and capsule excretion). Patients and methods  Patients scheduled for follow-up colonoscopy due to previous neoplastic findings or familial history of colorectal cancer aged 18 to 70 years were eligible. Bowel preparation was 2-L split doses of polyethylene glycol. Patients were randomized to three booster regimens of either polyethylene glycol (Group A), sulfate-based solution (Group B) or polyethylene glycol with iodine oral contrast (Group C). Results  One hundred eighty participants were included and randomized into three groups of 60. Capsule excretion was 70 % (95 % CI: 58 - 80) in Group A, 73 % (95 % CI: 61 - 83) in Group B and in 68 % (95 % CI: 56 - 79) in Group C, no statistically significant differences. Bowel cleansing grade was statistically significant better in Group B compared to Group A ( P  = 0.03), but there were no statistically significant differences between Groups C and A ( P  = 0.40). Complete examination rate was 65 % (95 % CI: 53 - 77), 72 % (95 % CI: 61 - 83) and 62 % (95 % CI: 50 - 74) in Group A, B and C respectively, not statistically significant different. Conclusions  Sulfate-based solution resulted in statistically significant better bowel cleansing compared to polyethylene glycol. Overall the excretion and completion rate was suboptimal. Achieving a high completion rate using patient-tolerable and low-risk compounds is still a challenge.

Association of clinical and inflammatory markers with small bowel capsule endoscopy findings in Crohn's disease

BACKGROUND

Mucosal healing is an established treatment endpoint in Crohn's disease (CD). Still, clinical indices and inflammatory markers are used widely in CD surveillance.

AIM

The aim of this study was to investigate the diagnostic performance as well as the relationship of C-reactive protein (CRP) and Crohn's Disease Activity Index (CDAI) with small bowel capsule endoscopy's (SBCE) inflammation scoring index, the Lewis Score (LS).

PATIENTS AND METHODS

CDAI, CRP, and SBCE findings of 30 CD patients with isolated small bowel disease were retrieved from our academic institution patient records and were analyzed statistically.

RESULTS

SBCE showed significant mucosal inflammation [mean (SD) LS: 1599 (1380)], in nine (60.0%) of 15 patients who were in both clinical and biochemical remission. CDAI and CRP showed a weak and moderate correlation with LS (r=0.317, P=0.088 and r=0.516, P=0.004, respectively). The diagnostic performance of CDAI and CRP in predicting mucosal inflammation was as follows: sensitivity 23.8 and 52.4%; specificity 100 and 66.7%; positive predictive value 100 and 78.6%; and negative predictive value 36.0 and 37.5%. The area under the curve toward endoscopic activity prediction was 0.70 and 0.69, respectively.

CONCLUSION

Both CDAI and CRP underestimated endoscopic activity as expressed by the LS in a significant proportion of patients with quiescent disease.

Colon capsule endoscopy for inflammatory bowel disease

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

Colon capsule endoscopy to screen for colorectal neoplasia in those with family histories of colorectal cancer

BACKGROUND AND AIMS

Colon capsule endoscopy (CCE) has been recognized as an alternative for colorectal cancer (CRC) screening in average-risk people. Our aim was to prospectively assess the accuracy of CCE as a screening tool in first-degree relatives (FDRs) of people with CRC by using optical colonoscopy (OC) with segmental unblinding as the reference standard.

METHODS

Consecutive patients admitted with a CRC diagnosis (index cases) were prospectively evaluated and invited to contact their FDRs. Available FDRs were invited to undergo CCE and OC on the following day, with segmental unblinding of CCE results. Sensitivity, specificity, and predictive values/negative predictive values (PPV/NPV) of CCE were assessed for detecting patients with any polyp ≥6 mm and ≥10 mm.

RESULTS

A total of 177 FDRs (median age 57.0 years, 54.8% female) identified from 211 index cases were included. Both CCE and OC were completed in all the included FDRs. Overall, CCE identified 51 of 56 FDRs with polyps ≥6 mm (sensitivity 91%; 95% CI, 81-96) and correctly classified as negative 107 of 121 participants without lesions ≥6 mm (specificity 88%; 95% CI, 81-93). Per-patient positive and negative predictive values for ≥6 mm lesions were 78% (95% CI, 67-87) and 95% (95% CI, 90-98), respectively. CCE detected 24 of 27 patients with polyps ≥10 mm and correctly classified as negative 142 of 150 patients, corresponding to 89% sensitivity and 95% specificity. Post-CCE referral rates to colonoscopy were 37% and 18%, respectively.

CONCLUSIONS

CCE is an accurate method to screen FDRs of patients with CRC and could be offered as an alternative to those who decline or are unfit for colonoscopy screening. (Clinical trial registration number: NCT01184781.).

Diagnostic capability of colon capsule endoscopy for advanced colorectal cancer: A pilot study

BACKGROUND AND AIM

Colon capsule endoscopy (CCE) is a safe and effective method for detecting lesions in the colon. However, the sensitivity of CCE in detecting advanced colorectal cancer (CRC) has not been sufficiently evaluated. Therefore, the aim of the present study was to assess the sensitivity of CCE in detecting advanced CRC.

METHODS

Patients previously diagnosed with advanced CRC by conventional colonoscopy underwent CCE. Primary outcome measure was the sensitivity of CCE in detecting advanced CRC per patient and per lesion. Secondary parameters measured were the sensitivity of CCE in detecting polyps ≥6 mm and ≥10 mm in size in a per-lesion analysis and the safety of CCE.

RESULTS

Of the 21 advanced CRC lesions in 20 patients, 17 were detected by CCE. The per-patient and per-lesion sensitivities of CCE for detecting advanced CRC lesions were 85% (95% confidence interval [CI]: 62-97%) and 81% (95% CI: 58-95%), respectively. All advanced CRC lesions were diagnosed in the accessible region by CCE while the capsule was still functional. A significant association was found between incomplete CCE and failure to diagnose advanced CRC. No severe adverse events occurred.

CONCLUSION

The diagnostic capability of CCE in detecting advanced CRC was limited in cases of procedure incompletion. Refining procedures to increase CCE procedure completion rates are required to enhance CRC detection.

Clinical Practice Guidelines for the Use of Video Capsule Endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice.

METHODS

A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined.

CONCLUSIONS

CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.

Guideline for wireless capsule endoscopy in children and adolescents: A consensus document by the SEGHNP (Spanish Society for Pediatric Gastroenterology, Hepatology, and Nutrition) and the SEPD (Spanish Society for Digestive Diseases)

INTRODUCTION

Capsule Endoscopy (CE) in children has limitations based mainly on age. The objective of this consensus was reviewing the scientific evidence.

MATERIAL AND METHODS

Some experts from the Spanish Society of Gastroenterology (SEPD) and Spanish Society for Pediatric Gastroenterology, Hepatology, and Nutrition (SEGHNP) were invited to answer different issues about CE in children. These sections were: a) Indications, contraindications and limitations; b) efficacy of CE in different clinical scenarios; c) CE performance; d) CE-related complications; e) Patency Capsule; and f) colon capsule endoscopy. They reviewed relevant questions on each topic.

RESULTS

The main indication is Crohn's disease (CD). There is no contraindication for the age and in the event that the patient not to swallow it, it should be administered under deep sedation with endoscopy and specific device. The CE is useful in CD, for the management of OGIB in children and in Peutz-Jeghers syndrome (in this indication has the most effectiveness). The main complication is retention, which should be specially taken into account in cases of CD already diagnosed with malnutrition. A preparation regimen based on a low volume of polyethylene glycol (PEG) the day before plus simethicone on the same day is the best one in terms of cleanliness although does not improve the results of the CE procedure.

CONCLUSIONS

CE is safe and useful in children. Indications are similar to those of adults, the main one is CD to establish both a diagnosis and disease extension. Moreover, only few limitations are detected in children.

PillCam colon capsule endoscopy (PCCE) in colonic diseases

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

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

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

The role of small bowel capsule endoscopy and ileocolonoscopy in patients with nonspecific but suggestive symptoms of Crohn's disease

OBJECTIVES

Ileocolonoscopy (IC) and small bowel capsule endoscopy (SBCE) are essential tools in the investigation of suspected small bowel Crohn's disease (CD). Overutilization of SBCE should be avoided as it leads to unwanted healthcare expenses; thus, it is recommended when IC is normal and CD is still highly suspected. Our aim was to compare the role of SBCE and IC in the investigation of suspected CD irrespective of its location and assess the additional diagnostic benefit of SBCE over IC.

METHODS

This was a retrospective study of 91 patients with chronic abdominal pain and/or diarrhea. All patients were evaluated with both colonoscopy (with terminal ileum intubation where possible) and SBCE. The severity of inflammation on SBCE was assessed using the Lewis Score. Endoscopic findings were analyzed toward CD diagnosis.

RESULTS

The sensitivity of IC and SBCE in the diagnosis of either small bowel or colonic CD was 81.82 and 63.64%, whereas the specificity was 77.50 and 92.50%, respectively. Positive and negative predictive value was 33.33 and 96.88% for IC, as well as 53.85 and 94.87% for SBCE. Area under receiver operating characteristic curve was 0.797 for IC and 0.781 for SBCE. IC was superior to SBCE in diagnosing small and large bowel CD. SBCE showed the true extent of CD in one patient missed by IC. It identified lesions suggestive of CD in three patients with normal IC, one of whom was finally diagnosed with CD.

CONCLUSION

IC should be the initial diagnostic test in patients with nonspecific, but suggestive symptoms of CD. SBCE offers additional information on small bowel mucosa and disease extent.

Capsule endoscopy: The road ahead

Since its introduction into clinical practice 15 years ago, capsule endoscopy (CE) has become the first-line investigation procedure in some small bowel pathologies, and more recently, dedicated esophageal and colon CE have expanded the fields of application to include the upper and lower gastrointestinal disorders. During this time, CE has become increasingly popular among gastroenterologists, with more than 2 million capsule examinations performed worldwide, and nearly 3000 PubMed-listed studies on its different aspects published. This huge interest in CE may be explained by its non-invasive nature, patient comfort, safety, and access to anatomical regions unattainable via conventional endoscopy. However, CE has several limitations which impede its wider clinical applications, including the lack of therapeutic capabilities, inability to obtain biopsies and control its locomotion. Several research groups are currently working to overcome these limitations, while novel devices able to control capsule movement, obtain high quality images, insufflate the gut lumen, perform chromoendoscopy, biopsy of suspect lesions, or even deliver targeted drugs directly to specific sites are under development. Overlooking current limitations, especially as some of them have already been successfully surmounted, and based on the tremendous progress in technology, it is expected that, by the end of next 15 years, CE able to perform both diagnostic and therapeutic procedures will remain the major form of digestive endoscopy. This review summarizes the literature that prognosticates about the future developments of CE.

Evaluation of the clinical efficacy of colon capsule endoscopy in the detection of lesions of the colon: prospective, multicenter, open study

BACKGROUND

Colon capsule endoscopy (CCE) is a new procedure for colon imaging. Limited information is available regarding visualization of flat colon lesions and patient acceptability in Japan.

OBJECTIVE

The aims of this study were to evaluate the sensitivity of CCE in detecting polyps and other lesions compared with optical colonoscopy (OC) and to evaluate its safety and acceptability in a cohort of Japanese patients.

DESIGN

A prospective, open-label, clinical study in Japan.

SETTING

Multicenter.

PATIENTS

Patients referred for OC because of personal history of polyps ≥6 mm or any other colon lesion that required endoscopic or surgical treatment.

INTERVENTIONS

CCE followed by therapeutic colonoscopy.

MAIN OUTCOME MEASUREMENTS

The primary endpoint was per-patient sensitivity of CCE in detecting significant colon lesion. The secondary endpoints were CCE safety and patient acceptability.

RESULTS

Sixty-six of the 72 patients enrolled in the study were evaluated for efficacy. The per-patient sensitivity was 94% (95% confidence interval [CI], 88.2%-99.7%). The per-polyp sensitivity was 86.6% (95% CI, 81.3%-91.9%) when pathology-confirmed polyps were considered true positives. There were no adverse events related to CCE, and the acceptability of CCE was high.

LIMITATIONS

All patients had previously confirmed colon lesions, which may have falsely elevated the sensitivity of CCE.

CONCLUSION

CCE had a high sensitivity for detecting significant colon lesions. CCE was safe and had a high level of patient acceptability. (

CLINICAL TRIAL REGISTRATION NUMBER

University Hospital Medical Information Network, UMIN000007258.).

Colon capsule endoscopy leading to gastrointestinal stromal tumor (GIST) diagnosis after colonoscopy failure

BACKGROUND

Gastrointestinal stromal tumors are a subtype of mesenchymal tumors. In recent years a significant progress was made in their diagnosis and treatment which led to significant improvement of their prognosis. Endoscopy remains one of the main diagnostic methods. In the rare instance of colonoscopy failure, different approaches are available: different endoscope, computed tomography colonography, capsule endoscopy, use of an enteroscope.

CASE PRESENTATION

We present the case of a 75-year-old Caucasian man admitted for abdominal pain, diarrhea and weight loss. Two colonoscopy attempts failed in a different center and a decision to use colon capsule endoscopy was made. This exam revealed a submucosal mass located in the sigmoid colon. Surgery was performed and a local invading gastrointestinal stromal tumor was removed. This is the first image of a colonic gastrointestinal stromal tumor seen on capsule endoscopy.

CONCLUSION

Colon capsule is a useful diagnostic tool in selected patients after colonoscopy failure or contraindication.

Colon Capsule Endoscopy for the Detection of Colorectal Polyps: An Evidence-Based Analysis

BACKGROUND

Colorectal cancer, a leading cause of mortality and morbidity in Ontario, can be prevented through early diagnosis and removal of precancerous polyps. Colon capsule endoscopy is a relatively new, minimally invasive test for detecting colorectal polyps.

OBJECTIVE

The objectives of this analysis were to evaluate the diagnostic accuracy and safety of colon capsule endoscopy for the detection of colorectal polyps among adult patients with signs or symptoms of colorectal cancer or with increased risk of colorectal cancer, and to compare colon capsule endoscopy with alternative procedures.

REVIEW METHODS

A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid EMBASE, the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published between 2006 and 2014. Data on diagnostic accuracy and safety were abstracted from included studies. Quality of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

The search yielded 2,189 citations. Five studies, all of which evaluated PillCam COLON 2 (PCC2), met the inclusion criteria. The per-patient sensitivity and specificity for detecting colorectal polyps were meta-analyzed. Colon capsule endoscopy, using PCC2, had a pooled sensitivity and specificity of 87% (95% confidence interval [CI] 77%-93%) and 76% (95% CI 60%-87%), respectively, for the detection of a colorectal polyp at least 6 mm in size (GRADE: very low). PCC2 had a pooled sensitivity and specificity of 89% (95% CI 77%-95%) and 91% (95% CI 86%-95%), respectively, for the detection of a colorectal polyp at least 10 mm in size (GRADE: low). One study directly compared PCC2 with computed tomographic (CT) colonography and found no statistically significant difference in accuracy (GRADE: low). Few adverse events were reported with PCC2; 3.9% of patients (95% CI 2.4%-6.5%) experienced adverse effects related to bowel preparation. Capsule retention was the most serious adverse event and occurred in 0.8% of patients (95% CI 0.2%-2.4%) (GRADE: very low).

CONCLUSIONS

In adult patients with signs, symptoms, or increased risk of colorectal cancer, there is low-quality evidence that colon capsule endoscopy using the PCC2 device has good sensitivity and specificity for detecting colorectal polyps. Low-quality evidence does not show a difference in accuracy between colon capsule endoscopy and CT colonography. There is very low-quality evidence that PCC2 has a good safety profile with few adverse events; capsule retention is the most serious complication.

Colon capsule endoscopy

Colon capsule endoscopy (CCE) is a minimally invasive technique specifically designed to explore the colon without sedation and air insufflation. CCE may overcome some of the limitations of colonoscopy. Second-generation CCE (CCE-2) was proved accurate in detecting colonic neoplastic lesions when used in average-risk individuals. The evidence to date supports the use of CCE-2 in cases of colonoscopy failure, in patients unwilling to undergo colonoscopy, and when colonoscopy is contraindicated. Other potential applications, such as colorectal cancer screening or diagnostic surveillance of inflammatory bowel disease, require clarification.

Current status of capsule endoscopy through a whole digestive tract

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

Video capsule endoscopy: perspectives of a revolutionary technique

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

Colon capsule endoscopy: Current status and future directions

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

A series of images of digestive cancers using Pill Cam COLON2 video capsule endoscopy

Colon capsule endoscopy is regarded as an option to complement or even replace diagnostic colonoscopy in selected cases. Since capsule lacks the capability of taking biopsies, a diagnosis of colon cancer usually requires a further confirmation by colonoscopy. A series of seven patients who had highly suspicious lesions at capsule endoscopy (five-colon tumors, one gastric tumor and one small bowel tumor) and in whom the clinical decision and treatment was solely based on capsule findings, are presented. The diagnosis of cancer was confirmed in all cases by surgery and histology.

CONCLUSION

In selected patients with a high index of clinical suspicion of cancer, PillCam colon 2 capsule endoscopy might be a sufficient tool for diagnosis.

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

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

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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