Finding the solution for incomplete small bowel capsule endoscopy

Best Approach for Incomplete Colonoscopy: Colon Capsule Endoscopy or Repeat Conventional Colonoscopy?

Background: The most appropriate strategy for completing a previous incomplete colonoscopy (IC) is not standardized. We aimed to compare the efficacy and safety of two strategies for completing a previous IC: colon capsule endoscopy (CCE) versus repeat conventional colonoscopy. Methods: A retrospective cohort study that included consecutive adult patients referred to our center after IC under sedation due to irreducible loop formation or colonic fixed angulation was performed. Patients underwent CCE (PillCam COLON2 Medtronic®) or repetition of conventional colonoscopy under sedation. In this setting, an appropriate CCE progression was defined as the capsule reaching the segment achieved during the previous IC. Repeated conventional colonoscopy was considered complete when cecal intubation was accomplished. We compared the rate of appropriate CCE colon progression with the cecal intubation rate from repeated conventional colonoscopy. Quality of colon preparation, diagnostic yield, and rate of adverse events for CCE and colonoscopy was also analyzed. Results: A total of 192 CCE and 181 colonoscopies were performed for IC, primarily due to fixed angulation of the left colon (69.2%, n = 258). There were no significant differences between the two groups (CCE vs. colonoscopy) concerning age, sex, overweight/obesity status, previous abdominal surgery, and reasons for IC. The rate of appropriate colon progression with CCE was not significantly different from the cecal intubation rate of repeated colonoscopy (95.3% vs. 90.1%, p = 0.073, respectively), even after adjusting for the quality of colon preparation (p = 0.122), which differed significantly between the groups (76.0% vs. 92.8%, p < 0.001, respectively). There were no significant differences in overall colorectal findings identified between the CCE and colonoscopy groups (55.2% vs. 62.4%, p = 0.172, respectively), and no adverse events were reported in either group. Conclusions: Our findings suggest that both CCE and repeat conventional colonoscopy are effective and safe options for completing a previous IC.

Endoscopic GI placement of capsule endoscopy to investigate the small bowel: a multicenter European retrospective series of 630 procedures in adult patients

BACKGROUND AND AIMS

Small-bowel (SB) capsule endoscopy (CE) is a first-line procedure for exploring the SB. Endoscopic GI PlacemenT (EGIPT) of SB CE is sometimes necessary. Although experience with EGIPT is considerable in pediatric populations, we aimed to describe the safety, efficacy, and outcomes of EGIPT of SB CE in adult patients.

METHODS

The international CApsule endoscopy REsearch (iCARE) group set up a retrospective multicenter study. Patients over age 18 years who underwent EGIPT of SB CE before May 2022 were included. Data were collected from medical records and capsule recordings. The primary endpoint was the technical success rate of the EGIPT procedures.

RESULTS

Of 39,565 patients from 29 centers, 630 (1.6%) were included (mean age, 62.5 years; 55.9% women). The technical success of EGIPT was achieved in 610 procedures (96.8%). Anesthesia (moderate to deep sedation or general anesthesia) and centers with intermediate or high procedure loads were independent factors of technical success. Severe adverse events occurred in 3 patients (.5%). When technically successful, EGIPT was associated with a high SB CE completion rate (84.4%) and with a substantial diagnostic yield (61.1%). The completion rate was significantly higher when the capsule was delivered in the SB compared with when it was delivered in the stomach.

CONCLUSIONS

EGIPT of SB CE is highly feasible and safe, with a high completion rate and diagnostic yield. When indicated, it should be performed with patients under anesthesia, and the capsule should be delivered in the duodenum rather than the stomach for better SB examination outcomes.

TOP 100 and detection of colorectal lesions in colon capsule endoscopy: more than meets the eye

Colon capsule endoscopy (CCE) is a well-known method for the detection of colorectal lesions. Nevertheless, there are no studies reporting the accuracy of TOP 100, a CCE software tool, for the automatic detection of colorectal lesions in CCE. We aimed to evaluate the performance of TOP 100 in detecting colorectal lesions in patients submitted to CCE for incomplete colonoscopy compared with classic reading. A retrospective cohort study including adult patients submitted to CCE (PillCam COLON 2; Medtronic) for incomplete colonoscopy. Blinded for each other's evaluation, one experienced reader analyzed the TOP 100 images and the other performed classic reading to identify colorectal lesions. Detection of colorectal lesions, namely polyps, angioectasia, blood, diverticula, erosions/ulcers, neoplasia, and subepithelial lesions was assessed and TOP 100 performance was evaluated compared with the gold standard (classic reading). A total of 188 CCEs were included. Prevalence of colorectal lesions, polyps, angioectasia, blood, diverticula, erosions/ulcers, neoplasia, and subepithelial lesions were 77.7, 54.3, 8.5, 1.6, 50.0, 0.5, 0.5, and 1.1%, respectively. TOP 100 had a sensitivity of 92.5%, specificity of 69.1%, negative predictive value of 72.5%, positive predictive value of 91.2%, and accuracy of 87.2% for detecting colorectal lesions. TOP 100 had a sensitivity of 89.2%, specificity of 84.9%, negative predictive value of 86.9%, positive predictive value of 87.5%, and accuracy of 87.2% in detecting polyps. All colorectal lesions other than polyps were identified with 100% accuracy by TOP 100. TOP 100 has been shown to be a simple and useful tool in assisting the reader in the prompt identification of colorectal lesions in CCE.

Deep Learning-Based Real-Time Organ Localization and Transit Time Estimation in Wireless Capsule Endoscopy

BACKGROUND

Wireless capsule endoscopy (WCE) has significantly advanced the diagnosis of gastrointestinal (GI) diseases by allowing for the non-invasive visualization of the entire small intestine. However, machine learning-based methods for organ classification in WCE often rely on color information, leading to decreased performance when obstacles such as food debris are present. This study proposes a novel model that integrates convolutional neural networks (CNNs) and long short-term memory (LSTM) networks to analyze multiple frames and incorporate temporal information, ensuring that it performs well even when visual information is limited.

METHODS

We collected data from 126 patients using PillCam™ SB3 (Medtronic, Minneapolis, MN, USA), which comprised 2,395,932 images. Our deep learning model was trained to identify organs (stomach, small intestine, and colon) using data from 44 training and 10 validation cases. We applied calibration using a Gaussian filter to enhance the accuracy of detecting organ boundaries. Additionally, we estimated the transit time of the capsule in the gastric and small intestine regions using a combination of a convolutional neural network (CNN) and a long short-term memory (LSTM) designed to be aware of the sequence information of continuous videos. Finally, we evaluated the model's performance using WCE videos from 72 patients.

RESULTS

Our model demonstrated high performance in organ classification, achieving an accuracy, sensitivity, and specificity of over 95% for each organ (stomach, small intestine, and colon), with an overall accuracy and F1-score of 97.1%. The Matthews Correlation Coefficient (MCC) and Geometric Mean (G-mean) were used to evaluate the model's performance on imbalanced datasets, achieving MCC values of 0.93 for the stomach, 0.91 for the small intestine, and 0.94 for the colon, and G-mean values of 0.96 for the stomach, 0.95 for the small intestine, and 0.97 for the colon. Regarding the estimation of gastric and small intestine transit times, the mean time differences between the model predictions and ground truth were 4.3 ± 9.7 min for the stomach and 24.7 ± 33.8 min for the small intestine. Notably, the model's predictions for gastric transit times were within 15 min of the ground truth for 95.8% of the test dataset (69 out of 72 cases). The proposed model shows overall superior performance compared to a model using only CNN.

CONCLUSIONS

The combination of CNN and LSTM proves to be both accurate and clinically effective for organ classification and transit time estimation in WCE. Our model's ability to integrate temporal information allows it to maintain high performance even in challenging conditions where color information alone is insufficient. Including MCC and G-mean metrics further validates the robustness of our approach in handling imbalanced datasets. These findings suggest that the proposed method can significantly improve the diagnostic accuracy and efficiency of WCE, making it a valuable tool in clinical practice for diagnosing and managing GI diseases.

Incomplete small bowel capsule endoscopy: Risk factors and cost-effectiveness of real-time viewing

Background and study aims International guidelines recommend real-time viewing (RTV) in capsule endoscopy for gastric emptying monitoring, yet it is often overlooked in clinical practice. We aimed to assess risk factors for incomplete small bowel capsule endoscopy (SBCE) and evaluate the clinical relevance and cost-effectiveness of RTV implementation. Methods We included consecutive SBCEs from 2013 to 2020. RTV was not applied per local protocol. We used multivariate logistic regression to identify risk factors for incomplete SBCE, including prolonged gastric transit time (GTT) and prolonged small bowel transit time (SBTT). Results Analyzing 858 SBCEs, we observed a completion rate of 94.6%. Prolonged GTT and SBTT were present in 4.9% and 18.2% of complete SBCEs, and in 13% ( P =0.03) and 10.8% ( P =0.24) of incomplete SBCEs, respectively. Only 0.7% (6 of 858) had incomplete SBCE with prolonged GTT. In both univariate and multivariate analysis, a modifiable (prolonged GTT odds ratio [OR] 2.9; 95% confidence interval [CI] 1.1-7.5) and two unmodifiable risk factors (inpatient status OR 2.3; 95% CI 1.1-4.5) and history of incomplete SBCE (OR 4.2; 95% CI 1.3-13.7) were independently linked to higher incomplete SBCE rates. The pretest completion probability was 90.5% and 95.8% in patients with and without unmodifiable risk factors, respectively ( P <0.01). The direct cost of systematic RTV adoption and prokinetics administration would be €5059, aiming to identify and treat each case of prolonged GTT associated with incomplete SBCE. Conclusions Modern devices make incomplete SBCE rare, usually not tied to prolonged GTT. In a low-incidence scenario, widespread RTV use brings high costs and uncertain effectiveness.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of prokinetic agents in hospitalised adult patients: A scoping review

BACKGROUND

Gastrointestinal motility is important for adequate uptake of fluids and nutrition but is often impaired in hospitalised patients. Prokinetic agents enhance gastrointestinal motility and are prescribed for many hospitalised patients. In this scoping review, we aimed to systematically describe the body of evidence on the use of prokinetic agents in hospitalised patients. We hypothesised, that the body of evidence would be limited and derive from heterogeneous populations.

METHODS

We conducted this scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews statement. We searched Medline, Embase, Epistemonikos and the Cochrane Library for studies assessing the use of prokinetic agents on any indication and outcome in adult hospitalised patients. We used a modified version of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the certainty of evidence.

RESULTS

We included 102 studies with a total of 8830 patients. Eighty-six studies were clinical trials (84%), and 52 (60%) of these were conducted in the intensive care unit, with feeding intolerance as the main indication. In the non-intensive care setting the indications were wider; most studies assessed use of prokinetic agents before gastroscopy to improve visualisation. The most studied prokinetic agent was metoclopramide (49% of studies) followed by erythromycin (31%). In total 147 outcomes were assessed with only 67% of the included studies assessing patient-centred outcomes, and with gastric emptying as the most frequently reported outcome. Overall, the data provided no firm evidence on the balance between the desirable and undesirable effects of prokinetic agents.

CONCLUSIONS

In this scoping review, we found that the studies addressing prokinetic agents in hospitalised adults had considerable variations in indications, drugs and outcomes assessed, and that the certainty of evidence was judged to be low to very low.

Management of small bowel angioectasias diagnosed during video capsule endoscopy

Small bowel angioectasias (SBA) are vascular malformations consisting of thin-walled, dilated capillaries located in the gastrointestinal mucosa. They are responsible for 10% of all causes of gastrointestinal bleeding and 60% of small bowel bleeding pathologies. The diagnosis and management of SBA depend upon bleeding acuity, patient stability and patient characteristics. Small bowel capsule endoscopy is a relatively noninvasive diagnostic approach ideal for non-obstructed and hemodynamically stable patients. It is superior to computed tomography scans in visualizing mucosal lesions, such as angioectasias, as it provides mucosal views. Management of these lesions will depend on the patient's clinical condition and associated comorbidities, and very often consists of medical and/or endoscopic treatment delivered through small bowel enteroscopy.

Stepping it up: Physical activity is associated with a lower incidence of prolonged gastric transit time in capsule endoscopy

BACKGROUND AND AIM

Physical activity has been proposed as a potential factor influencing capsule endoscopy (CE) gastric transit time (GTT). However, there is no reported factual evidence confirming this association. We aimed to prospectively assess the effect of physical activity in the first hour of CE in the occurrence of prolonged GTT.

METHODS

This is a prospective study including consecutive patients undergoing CE. For each patient, a step counter was attached to the CE register. The number of steps during the first hour of the procedure was registered. The main outcome was prolonged GTT (CE remaining in the stomach for > 1 h). Outcomes were adjusted for possible confounders by multivariate analysis.

RESULTS

We included 100 patients, 60% undergoing small bowel CE and 40% colon CE. The mean number of steps in the first hour was significantly lower in patients with prolonged GTT (2009 ± 1578 steps) comparatively with those without prolonged GTT (3597 ± 1889 steps) (P < 0.001). On multivariate analysis including significant confounders, steps in the first hour were an independent predictor of prolonged GTT (P = 0.018). Single-handedly, the number of steps taken in the first hour had a good acuity for predicting prolonged GTT (area under the curve = 0.74; P < 0.001), with an optimal cut-off of 2000 steps (sensitivity 81.3% and specificity 70%).

CONCLUSIONS

Physical activity during the first hour of CE significantly decreased the occurrence of prolonged GTT. These findings pave the way for further definition of clear instructions to give to patients undergoing CE.

The Prediction of Inadequate Colon Capsule Cleansing: A Cohort Selection Guided by CC-CLEAR

INTRODUCTION

In order to optimize the rate of adequate cleansing in colon capsule, it may be important to identify risk factors that can predict a suboptimal colon preparation.

AIM

To define predictive factors for inadequate bowel preparation in colon capsule, according to CC-CLEAR (Colon Capsule CLEansing Assessment and Report).

METHODS

Retrospective, single center, cohort study. Patients' demographics, data, and quality of bowel preparation, according to CC-CLEAR, were collected retrospectively. A univariate analysis tested the association between covariables and the outcome, inadequate cleansing. The statistically significant variables were included in multivariable logistic binary regression, and a receiver operating characteristic curve (ROC) assessment was performed.

RESULTS

We included 167 consecutive colon capsules. Sixty-eight percent (n = 114) of patients were female, with a mean age of 64 years. The main indication for colon capsule was previous incomplete colonoscopy, in 158 patients (94.6%). The colon capsules cleansing was graded as good or excellent in 96 patients (57.5%) and as inadequate in 71 (42.5%), according to CC-CLEAR. The variables inadequate previous colon cleansing (OR adjusted 41.72 [95% CI 12.57-138.57], p value < 0.001); chronic laxative (OR adjusted 4.86 [95% CI 1.08-21.79], p value = 0.039); antidepressant (OR adjusted 5.00 [95% CI 1.65-15.16], p value = 0.004), and impaired mobility (OR adjusted 5.54 [95% CI 1.17-26.31], p value = 0.031) were independently associated with the outcome inadequate cleansing, after adjusting for confoundment. The model presented an excellent discriminative power towards the outcome variable (AUC ROC 0.937 [CI 95% 0.899-0.975], p value < 0.001).

CONCLUSION

A previous inadequate colon cleansing, the use of chronic laxative and antidepressant, or impaired mobility are predictors of inadequate colon capsule cleansing, as assessed by the CC-CLEAR. These 4 predictors come together as a model enabling an accurate categorization of the patients at major risk of inadequate bowel preparation for capsule colonoscopy, with an excellent discriminative power and performance, which seems useful for the selection of patients for tailored optimization of the colon cleansing protocol.

CC-CLEAR (Colon Capsule Cleansing Assessment and Report): the novel scale to evaluate the clinical impact of bowel preparation in capsule colonoscopy - a multicentric validation study

BACKGROUND

Colon Capsule Cleansing Assessment and Report (CC-CLEAR) is a novel quantitative bowel preparation scale for colon capsule.

AIM

The aim of this study is to validate the association between CC-CLEAR's classification and major CC outcomes: lesion detection rate, surveillance recommendations and post-CC endoscopic treatment.

METHODS

Multicentric cohort of consecutive CCs. An expert's panel decided post-CC recommendations. Data included CC-CLEAR and Leighton-REX scales. Major CC outcomes were associated with the different cleansing grades.

RESULTS

From 168 CC's included, findings were reported in 123 (73.2%), 67 (54.4%) of those being colorectal polyps. CC-CLEAR influenced CC's lesion detection (OR 1.25 95% IC [1.07-1.46], p-value .004) and polyp detection rate (OR 1.22 95% IC [1.04-1.43], p-value.014). Thirty-two (19%) post-CC colonoscopies were recommended, including 22 (68.75%) with at least one polypectomy. CC-CLEAR was associated with post-CC colonoscopy treatment (OR 1.40 95% IC [1.07-1.84], p-value .015). Regarding surveillance, CC-CLEAR influenced the decision for immediate CC repetition (OR 0.21 95% IC [0.12-0.36], p-value < .001) and the recommendation for CC in 3-5 years' time (OR 1.47 95% IC [1.50-1.86], p-value < .002). The Leighton-Rex scale was not correlated with major CC outcomes.

CONCLUSION

CC-CLEAR impacts major CC outcomes: lesion detection, surveillance recommendations and post-CC endoscopic treatment.

RHEMITT score: Predicting the risk of mid gastrointestinal rebleeding after small bowel capsule endoscopy: A prospective validation

BACKGROUND AND AIM

The RHEMITT score (Renal disease; Heart failure; Endoscopic findings; Major bleeding; Incomplete SBCE; Tobacco; Treatment by enteroscopy) was the first score to accurately predict the individual risk of small bowel rebleeding after capsule endoscopy (SBCE). The aim of the study is on the prospective validation of the RHEMITT score.

METHODS

Cohort of consecutive patients with mid-gastrointestinal bleeding (MGIB) submitted to SBCE and followed prospectively, during at least 12 months, since 2017 until 2020. Rebleeding was defined as an overt bleeding event (melena or hematochezia) or a hemoglobin decrease of at least 2 g/dL. The RHEMITT score was calculated for each patient and the rebleeding rates compared. The performance of the score was tested by calculating the area under curve of the receiver operator characteristic curve. A rebleeding-free survival was assessed, corresponding to the period between the date of SBCE and the date of the first post-SBCE rebleeding event.

RESULTS

We included 162 patients, 102 (62.9%) were female, with a mean age of 64 years old. The sensitivities and specificities of the score grades for predicting rebleeding were as following: for low-risk patients, 0% (0-10%) and 28.8% (21.1-36.5%); for intermediate-risk patients, 23.3% (8.2-38.4%) and 72% (64.3-79.7%); for high-risk patients, 76.7% (61.6-91.8%) and 99.2% (97.7-100%), corresponding to an area under curve of the receiver operator characteristic of 0.988 (P < 0.001). Kaplan-Meyer plots were statistically different according to the attributed risk (log-rank P value <0.001; Breslow-Wilcoxon P value <0.001).

CONCLUSION

The RHEMITT score performed with excellent discriminative power in predicting rebleeding risk, and we herewith propose a surveillance of MGIB patients guided by the RHEMITT score.

Endoscopic Delivery Method Using a Retrieval Net for Patients with Small-Bowel Capsule Endoscopy Stagnation in the Stomach

With the increasing use of capsule endoscopy (CE), screening tests for the small bowel can be performed with minimal invasiveness. However, occasionally, the entire small bowel cannot be observed because of decreased peristalsis of the stomach. For such cases, we perform delivery of CE by an endoscope. We retrospectively examined the usefulness of the endoscopic delivery method using a retrieval net for patients with CE stagnation in the stomach. From 2,270 patients who underwent small-bowel CE at Hiroshima University Hospital from January 2013 to January 2020, 29 consecutive patients (1.3% of the total number) in whom the small bowel could not be observed due to CE stagnation in the stomach at the time of the initial CE underwent the endoscopic delivery method using a retrieval net for secondary small-bowel CE. This study included 16 male (55%) and 13 female (45%) patients with a mean age of 69.2 ± 13.2 years. 11 patients (38%) had a history of gastrointestinal surgical resection. The entire small bowel could be observed in 19 patients (66%), and CE reached the terminal ileum in the remaining patients. A history of gastrointestinal surgical resection was significantly more frequent in the group where the entire small bowel could not be observed. The rate of small-bowel lesion detection was 55% (16/29). There were no adverse events associated with our endoscopic delivery method. Thus, the endoscopic delivery method using a retrieval net for patients with initial CE stagnation in the stomach may be safe and useful for the detection of small-bowel lesions.

Small-bowel transit time in capsule endoscopy: a determinant factor for the diagnosis of small-bowel bleeding

BACKGROUND

small-bowel capsule endoscopy (SBCE) is the gold standard for the study of small-bowel bleeding (SBB). Recent studies suggest that longer small-bowel transit times (SBTT) may be associated with a higher diagnostic yield of SBCE.

AIM

the aim of the study was to investigate if longer SBTT is a predictive factor of positive findings on SBCE in a population that underwent SBCE for suspected SBB.

METHODS

a retrospective single-center study including consecutive SBCEs between May 2012 and May 2019, due to suspected SBB. A positive SBCE was considered in the presence of lesions with high bleeding potential such as ulcers, angioectasias, and tumors (P2 lesions, according to the Saurin classification).

RESULTS

we included 372 patients, 65.9 % female, with a median age of 67 (IQR: 19-97) years. We observed that patients with P2 lesions (n = 131; 35.2 %) in SBCE exhibited a longer SBTT (p = 0.01), were older (p < 0.001), were more frequently male (p = 0.019), and suffered more frequently from arterial blood hypertension (p = 0.011), diabetes (p = 0.042), chronic kidney disease (p = 0.003), and heart failure (p = 0.001). In the logistic analysis, significant predictive factors for the presence of P2 lesions included age (OR: 1.027; 95 % CI: 1.009-1.045; p = 0.004), SBTT (OR: 1.002; 95 % CI: 1.001-1.005; p = 0.029), and male gender (OR: 1.588; 95 % CI: 1.001-2.534; p = 0.049).

CONCLUSIONS

patients with longer SBTT had higher rates of lesions with high bleeding potential (P2). SBTT along with previously well-defined factors such as age and male gender were the only independent predictive factors for the presence of P2 lesions. These findings may suggest that a slower passage of the capsule through the small bowel may allow a better diagnostic yield for significant lesions.

Lavage, Simethicone, and Prokinetics-What to Swallow with a Video Capsule

The development of new capsules now allows endoscopic diagnosis in all segments of the gastrointestinal tract and comes with new needs for differentiated preparation regimens. Although the literature is steadily increasing, the results of the conducted trials on preparation are sometimes conflicting. The ingestion of simethicone before gastric and small bowel capsule endoscopy for prevention of air bubbles is established. The value of a lavage before small bowel capsule endoscopy (SBCE) is recommended, although not supported by all studies. Ingestion in the morning before the procedure seems useful for the improvement of mucosa visualization. Lavage after swallowing of the capsule seems to improve image quality, and in some studies also diagnostic yield. Prokinetics has been used with first generation capsules to shorten gastric transit time and increase the rate of complete small bowel visualization. With the massively prolonged battery capacity of the new generation small bowel capsules, prokinetics are only necessary in significantly delayed gastric emptying as documented by a real-time viewer. Lavage is crucial for an effective colon capsule or pan-intestinal capsule endoscopy. Mainly high or low volume polyethylene glycol (PEG) is used. Apart from achieving optimal cleanliness, propulsion of the capsule by ingested boosts is required to obtain a complete passage through the colon within the battery lifetime. Boosts with low volume sodium picosulfate (NaP) or diatrizoate (gastrografin) seem most effective, but potentially have more side effects than PEG. Future research is needed for more patient friendly but effective preparations, especially for colon capsule and pan-intestinal capsule endoscopy.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Colon Capsule CLEansing Assessment and Report (CC-CLEAR): a new approach for evaluation of the quality of bowel preparation in capsule colonoscopy

BACKGROUND AND AIMS

Current colon capsule (CC) cleansing grading scales rely on subjective parameters and lack proper interobserver agreement. We should strive for higher intra- and interobserver agreement for the evaluation of the cleansing quality of CCs. Here we sought to validate a new grading scale for the evaluation of CC cleansing.

METHODS

For the new grading scale, named Colon Capsule CLEansing Assessment and Report (CC-CLEAR), the colon was divided in 3 segments: right-sided, transverse, and left-sided colon. Each segment was scored according to an estimation of the percentage of visualized mucosa (0, <50%; 1, 50%-75%; 2, >75%; 3, >90%). The overall cleansing classification was a sum of each segment score, grading between excellent (8-9), good (6-7), and inadequate (0-5). Any segment scoring ≤1 resulted in inadequate overall classification. Videos were reviewed and scored using CC-CLEAR and the Leighton-Rex grading scale by 2 experienced operators blinded to each other. Kendall's coefficient evaluated inter- and intraobserver agreement.

RESULTS

We included 58 consecutive CCs, corresponding to 75.9% women, with a mean age of 65 years. Overall cleansing CC-CLEAR classifications were as follows: reader A, 22.4% (n = 13) excellent, 31% (n = 18) good, and 46.5% (n = 27) inadequate; and reader B, 24.1% (n = 14) excellent, 22.4% (n = 13) good, and 53.4% (n = 31) inadequate. CC-CLEAR interobserver agreement was superior to the Leighton-Rex scale (Kendall's W .911 vs .806, respectively; P < .01). The intraobserver agreement for CC-CLEAR was excellent for both readers (P > .01).

CONCLUSIONS

CC-CLEAR is a new practical and reliable grading scale for the evaluation of bowel preparation quality using a CC, with excellent inter- and intraobserver agreement.

Capsule endoscopy: Is the software TOP 100 a reliable tool in suspected small bowel bleeding?

BACKGROUND

Small bowel capsule endoscopy (SBCE) is the reference standard tool for diagnosing small bowel bleeding (SBB). The "TOP 100", which performs an automatic selection of the 100 images that mostly likely contain abnormalities, emerged as a new functionality of the RAPID Reader® software in 2017.

AIM

To compare the concordance of findings between the standard reading (SR) and the use of TOP 100 in suspected SBB.

METHODS

Retrospective study, including consecutive patients submitted to SBCE for suspected SBB. Two experienced readers performed SR and reported the most important findings. Another experienced reader, who was blinded to the SR results, reviewed all the SBCE videos using TOP 100 and reported the most important findings. The relevant findings were defined as the presence of high bleeding potential lesions (P2).

RESULTS

97 patients were included. The TOP 100 detected 81/97(83.5%) of the P2 lesions, in particular 64/67(95.5%) of the angioectasias and 17/30(56.7%) of the ulcers. The TOP 100 identified all sites of active bleeding (n = 9).

CONCLUSION

The TOP 100 identified all sites of active bleeding, as well as the vast majority of significant lesions (83.5%); in particular, it detected over 95% of the angioectasias. Although SR remains the reference standard in the SBCE review, these findings demonstrate that TOP 100 allows for a quick preview reading constituting an important asset in the identification of lesions that may require priority full review and intervention planning.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

How should we select suspected Crohn's disease patients for capsule enteroscopy?

Background: In suspected Crohn's disease (CD), non-diagnostic ileocolonoscopies are often followed by small bowel capsule endoscopy (SBCE). Adequate pre-selection of patients for SBCE is a key to optimize allocation of resources. We aimed to establish a rational approach for the CD diagnostic workflow, based on biochemical profile of patients with suspected CD, targeting an optimization of patients' selection for SBCE. Methods: Multicenter cohort study includes consecutive patients with suspected undergoing SBCE after non-diagnostic ileocolonoscopy. Minimum follow-up period after the capsule enteroscopy was six months. The outcome was confirmation of CD diagnosis. Univariate analysis and logistic regression were performed. Results: In included 220 patients, 62.3% of women were with a mean age of 41 years [26-54]. A confirmed diagnosis of CD was established in 98 patients (44.5%). The initial univariate analysis identified variables above the threshold of marginal statistical association toward CD diagnosis (p < .15). The regression model identified high CRP levels (OR 1.028 p = .128) and low serum Iron (OR 0.990 p = .025) as the independent variables with consistent correlation with CD diagnosis. Those two variables present a suitable discriminative power (AUC = 0.669, p < .001) for the diagnosis of CD. Conclusion: In suspected CD, low serum iron and elevated CRP had a statistically significant association with CD diagnosis, being helpful to identify patients with higher CD probability before SBCE. However, the lack of a proper validation of the model leads us to currently recommend SBCE to all patients with suspected CD and negative ileocolonoscopy, as no specific biochemical profile can be used to confidently exclude small bowel CD.

Diagnosis and therapeutic strategies for small bowel vascular lesions

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

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

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.

Diagnostic value of OMOM capsule endoscopy for small bowel diseases in adults

The present study aimed to determine the diagnostic yield of OMOM capsule endoscopy for small bowel diseases in adults. A total of 89 patients, including 45 cases of obscure abdominal pain, 22 of chronic diarrhea, 18 of obscure gastrointestinal bleeding and 4 of obscure anemia were enrolled in the present study. The transit time of the endoscopy capsule in the digestive tract was recorded and the testing results were analyzed. All detections were completed except for four capsule retentions and the completion rate was 95.51%. The average transit time of the endoscopy capsule in the esophagus, stomach and small intestine was 62.18±64.23 sec, 67.46±63.13 and 346.53±102.81 min, respectively. Of the 89 patients, 54 (60.67%) were found to have lesions, among which 19 had mucosal erosion (21.35%), 15 had anabrosis (16.85%), 9 were diagnosed with polyps (10.11%), 5 with angiodysplasia (5.62%); furthermore, tumors were identified in 5 patients (5.62%) and ancylostomiasis in 1 patient (1.12%). The results confirmed the feasibility and validity of OMOM capsule endoscopy for diagnosing small bowel diseases in adults.

Perianal Crohn's disease - association with significant inflammatory activity in proximal small bowel segments

OBJECTIVES

Perianal Crohn's disease (CD) prevalence varies according to the disease location, being particularly frequent in patients with colonic involvement. We aimed to evaluate small bowel involvement and compare small bowel capsule endoscopy findings and inflammatory activity between patients with and without perianal disease.

MATERIALS AND METHODS

Retrospective single-center study including 71 patients - all patients with perianal CD (17 patients) who performed a small bowel capsule endoscopy were included, and non-perianal CD patients were randomly selected (54 patients). Clinical and analytical variables at diagnosis were reviewed. Statistical analysis was performed with SPSS v21.0 and a two-tailed p value <.05 was defined as indicating statistical significance.

RESULTS

Patients had a median age of 30 ± 16 years with 52.1% females. Perianal disease was present in 23.9%. Patients with perianal disease had significantly more relevant findings (94.1% vs 66.6%, p = .03) and erosions (70.6% vs 42.6%, p = .04), however, no differences were found between the two groups regarding ulcer, villous edema and stenosis detection. Overall, patients with perianal disease had more frequently significant small bowel inflammatory activity, defined as a Lewis Score ≥135 (94.1% vs 64.8%, p = .03), and higher Lewis scores in the first and second tertiles (450 ± 1129 vs 0 ± 169, p = .02 and 675 ± 1941 vs 0 ± 478, p = .04, respectively). No differences were found between the two groups regarding third tertile inflammatory activity assessed with the Lewis Score.

CONCLUSION

Patients with perianal CD have significantly higher inflammatory activity in the small bowel, particularly in proximal small bowel segments, when compared with patients without perianal disease.

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.

ORBIT score: an useful predictor of small bowel rebleeding in patients under chronic anticoagulation

BACKGROUND AND STUDY AIMS

Available scoring systems to assess the risk for major bleeding in patients on chronic anticoagulation seem inadequate in predicting higher diagnostic yields of small bowel capsule endoscopy (SBCE) or higher rebleeding rates in patients with suspected small bowel bleeding. The aim of this study was to evaluate the ability of the new ORBIT score in predicting positive findings of SBCE or higher rebleeding rates in chronically anticoagulated patients with suspected small bowel bleeding.

PATIENTS AND METHODS

Retrospective analysis of 570 patients who consecutively underwent SBCE for the study of suspected small bowel bleeding. For each of the 67 patients who were on chronic anticoagulation, ORBIT score (Older age, Reduced hemoglobin/hematocrit, Bleeding history, Insufficient kidney function and Treatment with antiplatelets) was calculated. Patients were classified as high-risk (ORBIT score ≥4) or low/intermediate-risk (ORBIT score <4). Data on SBCE findings, diagnostic yield and rebleeding were compared between groups.

RESULTS

When ORBIT score was calculated, 41 and 26 patients were classified as low/intermediate-risk and high-risk, respectively. When low/intermediate-risk and high-risk groups were compared, no differences were found in the diagnostic yield of SBCE (39.0% vs. 23.1%; p = .176). However, in high-risk patients, rebleeding was significantly more common than in low/intermediate-risk patients (80.0% vs. 36.6%; p = .003).

CONCLUSIONS

In patients presenting with suspected small bowel bleeding and on chronic anticoagulation, the new ORBIT score seems promising in identifying those with a higher risk of rebleeding, in whom a closer follow-up and a more aggressive diagnostic and therapeutic strategy is advisable.

Suspected blood indicator in capsule endoscopy: a valuable tool for gastrointestinal bleeding diagnosis

BACKGROUND

Small bowel bleeding is a leading indication for small bowel capsule endoscopy. The Suspected Blood Indicator (SBI) is a software feature directed to automatically detect bleeding lesions during small bowel capsule endoscopy.

OBJECTIVE

- We aimed to assess SBI diagnostic accuracy for small bowel haemorrhage or potentially bleeding lesions during small bowel capsule endoscopy for small bowel bleeding. Methods - Single-centre retrospective study including 281 consecutive small bowel capsule endoscopy performed for small bowel bleeding during 6 years. The investigators marked lesions with high bleeding potential (P2), such as angioectasias, ulcers and tumours, as well as active bleeding during regular small bowel capsule endoscopy viewing with PillCam SB2(r). All small bowel capsule endoscopy were independently reviewed by another central reader using SBI.

RESULTS

- Among the 281 patients, 29 (10.3%) presented with active haemorrhage while 81 (28.9%) presented with a P2 lesion. The most frequently observed P2 lesions were angioectasias (52), ulcers (15), polyps (7) and ulcerated neoplasias (7). SBI showed a 96.6% (28/29) sensitivity for active small bowel bleeding, with a 97.7% negative predictive value. Regarding P2 lesions, the SBI displayed an overall sensitivity of 39.5%, being highest for ulcerated neoplasias (100%), but significantly lower for angioectasias (38.5%) or ulcers (20.0%).

CONCLUSION

Although SBI sensitivity for the automatic detection of potentially bleeding lesions was low, it effectively detected active small bowel bleeding with very high sensitivity and negative predictive value.

Uncovering the uncertainty: Risk factors and clinical relevance of P1 lesions on small bowel capsule endoscopy of anemic patients

AIM

To identify risk factors for P1 lesions on small bowel capsule endoscopy (SBCE) and to describe the natural history of anemic patients with such type of lesions.

METHODS

One hundred patients were consecutively selected for a case-control analysis performed between 37 cases with P1 lesions and 63 controls with negative SBCE. Age, gender, comorbidities and regular medication were collected. Rebleeding, further investigational studies and death were also analyzed during the follow-up.

RESULTS

No significant differences on gender, median age or Charlson index were found between groups. Although no differences were found on the use of proton pump inhibitors, acetylsalicylic acid, anticoagulants or antiplatelet agents, the use of non-steroidal anti-inflammatory drugs (NSAID) was associated with a higher risk of P1 lesions (OR = 12.00, 95%CI: 1.38-104.1). From the 87 patients followed at our center, 39 were submitted to additional studies for investigation of iron-deficiency anemia (IDA), and this was significantly more common in those patients with no findings on SBCE (53.7% vs 30.3%, P = 0.033). A total of 29 patients had at least one rebleeding or IDA recurrence episode and 9 patients died of non-anemia related causes but no differences were found between cases and controls.

CONCLUSION

P1 lesions are commonly found in patients with IDA submitted to SBCE. The use of NSAID seems to be a risk factor for P1 lesions. The outcomes of patients with P1 lesions do not differ significantly from those with P0 lesions or normal SBCE.

Video capsule endoscopy completion and total transit times are similar with oral or endoscopic delivery

BACKGROUND AND STUDY AIMS

Video capsule endoscopy (VCE) is limited by incomplete procedures. There are also contraindications to the standard ingestion of the capsule that require endoscopic placement. Our aim was to compare the study completion rate of VCE after oral ingestion and endoscopic deployment.

PATIENTS AND METHODS

We performed a review of all VCE from April 2010 through March 2013. Inpatient and outpatient cohorts grouped by the method of capsule delivery were formed and compared. Multivariable logistic regression modeling was utilized adjusting for variables with a P value ≤ 0.1 in group comparisons. Log-rank analysis was used to compare transit times.

RESULTS

A total of 687 VCE were performed, including 316 inpatient (36 endoscopic deployment, 280 oral ingestion) and 371 outpatient (20 endoscopic deployment, 351 oral ingestion). For VCE on hospitalized patients, the completion rates were similar after endoscopic deployment and oral ingestion (72 % vs 73 %, P = 0.94). The completion rates were also similar for ambulatory patients (90 % vs 87 %, P = 0.69). There remained no difference after multivariable modeling for inpatients (P = 0.71) and outpatients (P = 0.46). Total transit times were not significantly different.

CONCLUSIONS

VCE completion rates and total transit times are similar after oral or endoscopic deployment for both hospitalized and ambulatory patients. Endoscopic placement is effective in patients with contraindications to standard oral ingestion, but should otherwise be avoided to limit unnecessary procedural risks and costs.

Contrast-Enhanced Cross Sectional Imaging and Capsule Endoscopy: New Perspectives for a Whole Picture of the Small Bowel

Small bowel evaluation is a challenging task and has been revolutionized by high-quality contrasted sectional imaging (CT enterography - CTE) and magnetic resonance enterography (MRE) as well as by small bowel capsule endoscopy (SBCE). The decision of which technique to employ during the investigation of small bowel diseases is not always simple or straightforward. Moreover, contraindications may preclude the use of these techniques in some patients, and although they are noninvasive procedures, may present with various complications. SBCE plays a crucial role in the investigation of both obscure gastrointestinal bleeding and Crohn's disease, but it is also useful for surveillance of patients with Peutz-Jeghers syndrome, while CTE is very accurate in small bowel tumours and in established Crohn's Disease, and its use in patients presenting with gastrointestinal bleeding is increasing. MRE, an expensive and not widely available technique, is essential for the study of patients with Crohn's Disease, and presents an attractive alternative to SBCE in Peutz-Jeghers syndrome surveillance. These diagnostic modalities are often not competitive but synergistic techniques. Knowing their characteristics, strengths and limitations, indications, contraindications and potential complications, as well as the adaptation to local availability and expertise, is essential to better select which procedures to perform in each patient, both safely and effectively, in order to optimize management and improve patient outcomes.

Capsule Endoscopy: Diagnostic Accuracy of Lewis Score in Patients with Suspected Crohn's Disease

BACKGROUND

The Lewis Score (LS) aims to standardize the method of quantification of small bowel inflammatory activity detected by the small bowel capsule endoscopy (SBCE). The aim of this study was to evaluate the diagnostic accuracy of the LS in patients with suspected CD undergoing SBCE.

METHODS

We performed a retrospective study including patients who underwent SBCE for suspected CD between September 2006 and February 2013. Patients were grouped according to the criteria of the International Conference on Capsule Endoscopy for the definition of suspected CD. Inflammatory activity on SBCE was objectively assessed by determining the LS.

RESULTS

Ninety-five patients were included. Group 1: 37 patients not fulfilling International Conference on Capsule Endoscopy criteria; Group 2: 58 patients with ≥ 2 International Conference on Capsule Endoscopy criteria. The diagnosis of CD was established in 38 patients (40%): 8 (21.6%) from group 1 and 30 from group 2 (51.7%) (P = 0.003). Among those patients, 34 had LS ≥ 135 (73.9%) and 4 had LS <135 (8.2%) at SBCE (P < 0.001). The LS ≥ 135 had an overall diagnostic accuracy of 83.2% with a sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of CD of 89.5%, 78.9%, 73.9%, and 91.8%, respectively.

CONCLUSIONS

The application of LS ≥ 135 as the cutoff value for the presence of significant inflammatory activity in patients undergoing SBCE for suspected CD may be useful to establish the diagnosis of CD. In patients with LS < 135, the probability of having CD confirmed on follow-up is low.

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.

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.

New evidence on the impact of antithrombotics in patients submitted to small bowel capsule endoscopy for the evaluation of obscure gastrointestinal bleeding

Objectives. Small bowel capsule endoscopy (SBCE) plays a decisive role in the obscure gastrointestinal bleeding (OGIB) diagnosis. Antithrombotics may increase bleeding risk in patients with preexistent lesions or through direct mucosal aggression. We aimed to correlate antithrombotics usage with lesions with bleeding potential found in SBCE. Methods. Retrospective single-center study including 274 consecutive SBCE performed over 7 years for OGIB. The lesions were classified as P0 (no bleeding potential), P1 (uncertain bleeding potential: erosions), and P2 (high bleeding potential: angioectasias, ulcers, and tumors). We assessed antiplatelet and anticoagulant drug use during the 60 days preceding SBCE. Results. One-third of the patients were under antithrombotic therapy. The diagnostic yield of SBCE for P2 lesions was 30.0%. Angioectasias (20.4%) were the most frequently observed lesions. There was a significant correlation between anticoagulant drug use and a higher incidence of P2 lesions in the small bowel (43.2% versus 26.5%; OR = 2.11, P = 0.026). We found no significant correlation between antiplatelets and lesions with bleeding potential in SBCE. Conclusions. Small bowel lesions with high bleeding potential were more frequently detected when the patient was on anticoagulant drugs, resulting in a twofold risk. Antiplatelet drugs were not associated with small bowel lesions.