Oral purgative and simethicone before small bowel capsule endoscopy

Small bowel cleansing for capsule endoscopy, systematic review and meta- analysis: Timing is the real issue

BACKGROUND

The optimal small bowel preparation modality before capsule endoscopy (SBCE) is still uncertain, regarding preparation type, dose and timing of administration.

AIM

The aim of the study is to evaluate the small bowel cleansing in patients undergoing small bowel capsule endoscopy after fasting alone or active treatment with purgative solutions.

METHODS

We searched 4 major scientific databases from inception to December 2021 for studies evaluating small bowel preparation before SBCE. Different preparation efficacy was compared using fasting as reference. Main variables evaluated in the current study were: preparation type, administration schedule and timing.

RESULTS

17 studies (27 treatment arms) with 2372 patients (male 47,4%) were included, mean age 54 years. Fasting alone VS overall purgative preparations pooled rate difference (RD) was 0.15 I2=81.5% p: 0.000. Sub-analysis for preparation schedule (day-before, split and same-day) and the time lapse showed that administration of PEG after the ingestion of capsule had the highest rate of adequate small bowel cleansing with a RD 0.33, administration between 1 and 6 h before SBCE had a RD 0.28, 6 to 12 h had a RD 0.21 and ≥12 h had a RD 0.05.

CONCLUSIONS

Timing of ingestion was found to be critical for bowel cleansing; the shorter time laps between the ingestion last dose of laxative and SBCE, the better was the mucosal visualization.

Small Bowel Capsule Endoscopy within 6 Hours Following Bowel Preparation with Polyethylene Glycol Shows Improved Small Bowel Visibility

Although bowel preparation influences small bowel visibility for small bowel capsule endoscopy (SBCE), the optimal timing for bowel preparation has not been established yet. Thus, the aim of the study was to evaluate the optimal timing of polyethylene glycol (PEG) for small bowel preparation before SBCE. This multicenter prospective observational study was conducted on patients who underwent SBCE following bowel preparation with polyethylene glycol (PEG). Patients were categorized into three groups according to the time used for completing PEG ingestion: group A, within 6 h; group B, 6-12 h; and group C, over 12 h. The percentage of unclean segment in small bowel (unclean image duration / small bowel transit time × 100) and small bowel visibility quality (SBVQ) were evaluated according to the time interval between the last ingestion of PEG and swallowing of small bowel capsule endoscope. A total of 90 patients were enrolled and categorized into group A (n = 40), group B (n = 27), and group C (n = 23). The percentage of unclean segment in the entire small bowel increased gradually from group A to C (6.6 ± 7.6% in group A, 11.3 ± 11.8% in group B, and 16.2 ± 10.7% in group C, p = 0.001), especially in the distal small bowel (11.4 ± 13.6% in group A, 20.7 ± 18.7% in group B, and 29.5 ± 16.4% in group C, p < 0.001). The proportion of patients with adequate SBVQ in group A was significantly (p < 0.001) higher (30/40, 75.0%) than that in group B (17/27, 63.0%) or group C (5/23, 21.7%). In multivariate analysis, group A was associated with an increased likelihood of adequate SBVQ compared with group C (odds ratio [OR]: 13.05; 95% confidence interval [CI]: 3.53-48.30, p < 0.001). Completing PEG ingestion within 6 h prior to SBCE could enhance small bowel visibility.

Preparation of small bowel capsule endoscopy (SBCE) with simethicone: A meta-analysis

BACKGROUND

It is disputed about optimal bowel preparation for small bowel capsule endoscopy (SBCE). This meta-analysis aimed to investigate the role of simethicone in intestinal preparation for SBCE.

METHODS

We searched four databases (PubMed, web of science, Embase, and Scopus databases) for relevant studies. Studies evaluating the effect of simethicone as an adjunct to SBCE bowel preparation were included. The random-effects model was applied to calculate the risk estimates. Primary outcomes include the degree of gas bubbles and small bowel visualization quality (SBVQ). Secondary outcomes include diagnostic yield (DY), gastric transit time (GTT), small bowel transit time (SBTT), and completion rate (CR).

RESULTS

A total of 10 studies were included (8 RCTs, 1 prospective, and 1 retrospective study). Compared with the control group, the simethicone group showed significant improvements in the degree of gas bubbling (RR = 2.05, 95%CI:1.56-2.71, P < 0.001, I² = 62%) and SBVQ (RR = 1.41, 95%CI: 1.20-1.65, P < 0.001, I² = 16%). Subgroup analysis showed that the SBVQ of simethicone group was better than fasting (RR = 2.62, 95% CI:1.49-4.59, P < 0.001, I² = 0%), mannitol (RR = 1.35, 95% CI: 1.14-1.59, P < 0.001, I² = 0%) and PEG group (RR = 1.32, 95%CI:1.06-1.65, P = 0.01, I² = 0%). No significant associations were found for DY, GTT, SBTT, and CR.

CONCLUSIONS

Simethicone for bowel preparation is useful to improve visualization and reduce the gas bubbling of SBCE.

Clinical utility of purgative bowel preparation before capsule endoscopy: a multicenter, blinded, randomized controlled trial

BACKGROUND AND AIMS

Optimal bowel preparation before capsule endoscopy (CE) is currently unknown. In this multicenter, blinded, randomized controlled trial, we assessed clinical effectiveness of 2 types of purgative regimen and a control arm of clear fluid only.

METHODS

Patients with suspected small intestinal bleeding were randomized into 3 arms: arm A, clear fluids only for 18 hours before CE and simethicone 200 mg in 150 mL water immediately before CE; arm B, same as A + 2 L of polyethylene glycol (PEG) 12 hours before CE; and arm C, same as A + 1 L PEG + sodium ascorbate 3 hours before CE. To assess diagnostic yield, lesions were classified either as highly relevant (P2) or less relevant (P0 or P1) lesions. Small-bowel visualization quality (SBVQ) was assessed using the Brotz score. Patient tolerability was assessed using the visual analog scale (0-10, with lower scores indicating better tolerability).

RESULTS

Two hundred twenty-nine patients completed the study. The mean age was 58.7 years (95% confidence interval, 29.3-87.9), and 47.2% were men. There was no significant difference in diagnosis of P2 lesions in arms A, B, and C (48.7%, 48.0%, and 45.9%, respectively; P = .94). Overall SBVQ and distal SBVQ were similar across the 3 arms (P = .94 and P = .68, respectively). Patients reported better tolerability in arm A (mean score, 1.5) compared with arms B and C (mean score, 3.5 and 2.6, respectively; P < .001).

CONCLUSIONS

The use of a purgative bowel preparation before CE does not improve diagnostic yield or small-bowel visualization and is associated with lower patient tolerance. (Clinical trial registration number: ACTRN 12614000883617.).

Evaluation by a Machine Learning System of Two Preparations for Small Bowel Capsule Endoscopy: The BUBS (Burst Unpleasant Bubbles with Simethicone) Study

Background: Bubbles often mask the mucosa during capsule endoscopy (CE). Clinical scores assessing the cleanliness and the amount of bubbles in the small bowel (SB) are poorly reproducible unlike machine learning (ML) solutions. We aimed to measure the amount of bubbles with ML algorithms in SB CE recordings, and compare two polyethylene glycol (PEG)-based preparations, with and without simethicone, in patients with obscure gastro-intestinal bleeding (OGIB). Patients & Methods: All consecutive outpatients with OGIB from a tertiary care center received a PEG-based preparation, without or with simethicone, in two different periods. The primary outcome was a difference in the proportions (%) of frames with abundant bubbles (>10%) along the full-length video sequences between the two periods. SB CE recordings were analyzed by a validated computed algorithm based on a grey-level of co-occurrence matrix (GLCM), to assess the abundance of bubbles in each frame. Results: In total, 105 third generation SB CE recordings were analyzed (48 without simethicone and 57 with simethicone-added preparations). A significant association was shown between the use of a simethicone-added preparation and a lower abundance of bubbles along the SB (p = 0.04). A significantly lower proportion of “abundant in bubbles” frames was observed in the fourth quartile (30.5% vs. 20.6%, p = 0.02). There was no significant impact of the use of simethicone in terms of diagnostic yield, SB transit time and completion rate. Conclusion: An accurate and reproducible computed algorithm demonstrated significant decrease in the abundance of bubbles along SB CE recordings, with a marked effect in the last quartile, in patients for whom simethicone had been added in PEG-based preparations, compared to those without simethicone.

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.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

[Optimal Bowel Preparation for Capsule Endoscopy and Device-assisted Enteroscopy]

For improved examination of video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), bowel preparation is an essential issue. Multiple factors like air bubbles, food material in the small bowel, and gastric and small bowel transit time affect the small bowel visualization quality (SBVQ), diagnostic yield (DY) and cecal completion rate (CR). Bowel preparation with polyethylene glycol (PEG) solution enhances SBVQ and DY, but it has no effect on CR. Bowel preparation with PEG solution 2 L is similar to PEG 4 L in SBVQ, DY, and CR. Bowel preparation with fasting or PEG solution combined with anti-foaming agents like simethicone enhance SBVQ, but it has no effect on CR. Bowel preparation with prokinetics is not commonly recommended. Optimal timing for purgative bowel preparation has yet to be established. However, the studies regarding bowel preparation for DAE are not sufficient. European Society of Gastrointestinal Endoscopy (ESGE) recommends 8-12 hours fasting from solid food and 4-6 hours fasting from liquids prior to the antegrade DAE. For retrograde DAE, colonoscopy preparation regimen is recommended. This article reviews the literature and ESGE, 2013 Korean published guidelines regarding bowel preparation for VCE and DAE, following suggestion for optimal bowel preparation for VCE and balloon enteroscopy.

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

Background

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

Objective

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

Animals

Forty dogs with overt or questionable GIB.

Methods

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

Results

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

Conclusions and Clinical Importance

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

From terminal ileitis to Crohn's disease: how capsule endoscopy is crucial to diagnosis

BACKGROUND AND AIMS

Terminal ileitis is a common condition and may be associated with a wide variety of diseases, mostly Crohn's disease. Although small bowel capsule endoscopy (SBCE) is a valuable diagnostic tool for small-bowel diseases, data regarding its diagnostic impact on isolated terminal ileitis are sparse. The aim of this study was to evaluate the diagnostic value of SBCE for isolated terminal ileitis detected during ileocolonoscopy and to assess predictive factors for Crohn's disease diagnosis.

METHODS

This is a retrospective study including consecutive patients undergoing SBCE after diagnosis of terminal ileitis without colonic mucosal abnormalities on ileocolonoscopy between January 2016 and September 2019.

RESULTS

This included 102 patients with isolated terminal ileitis on ileocolonoscopy. Positive findings on SBCE were found in 82.4% of patients. After performing SBCE, 61.8% of patients had a final diagnosis, being Crohn's disease the most common (34.3%), followed by NSAIDs enteropathy (12.7%). Extraintestinal manifestations (P = 0.003), weight loss (P = 0.02), abnormal imaging (P = 0.04) and positive SBCE findings (P = 0.001) were independently associated with Crohn's disease diagnosis. Regarding SBCE, presence of proximal small-bowel disease (P = 0.02), diffuse findings (P = 0.002) and moderate to severe inflammatory activity (Lewis score ≥ 790) (P < 0.001) were independently associated with Crohn's disease diagnosis.

CONCLUSION

SBCE is a valuable tool that should be systematically used in patients with isolated terminal ileitis on ileocolonoscopy, since it revealed a high diagnostic yield, supporting a definite diagnosis in almost two-thirds of patients, and Crohn's disease diagnosis in approximately one-third of patients. A diagnosis of Crohn's disease should be considered when a patient with terminal ileitis on ileocolonoscopy shows proximal involvement, diffuse findings and/or moderate to severe inflammatory activity on SBCE.

Clinical Outcomes between P1 and P0 Lesions for Obscure Gastrointestinal Bleeding with Negative Computed Tomography and Capsule Endoscopy

BACKGROUND

A simple classification for the relevance of lesions (P0, P1, and P2; no bleeding potential, less likely to bleed, and more likely to bleed, respectively) based on capsule endoscopy (CE) findings has been used. This study aimed at investigating rebleeding rates and predictive factors of P0 and P1 lesions after obtaining negative findings in both, CE and computed tomography (CT), for patients with obscure gastrointestinal bleeding (OGIB).

METHODS

Among 193 patients resulted in negative CE findings defined as P0 or P1 lesions, 84 patients with negative results on CT images were enrolled in this study. The rebleeding rates and predictive factors were assessed in the P0 and P1 groups.

RESULTS

Overall rebleeding rate in patients with negative CT and CE was 17.9%; 18.4% in the P0 group; 17.4% in the P1 group within a median follow-up duration of 18.5 months. In the P0 and P1 groups, the cumulative rebleeding rates were 9.2%, 25.4%, and 25.4%, and 6.9%, 11.8%, and 18.6% at 12, 24, and 60 months, respectively (p = 0.97). There were no independent rebleeding associated factors in the P0 group, whereas Charlson comorbidity index (CCI) (hazard ratio (HR) = 2.019, 95% confidence interval (CI): 1.158-3.519, p = 0.013), and initial low hemoglobin (Hb) level (<8 g/dL) (HR = 15.085, 95% CI: 1.182-192.514, p = 0.037) were independent predictive factors responsible for rebleeding in the P1 group.

CONCLUSIONS

Despite having negative findings on CT and CE, patients with OGIB have a significant potential rebleeding risk. Although there was no significant difference in rebleeding rates between the P0 and P1 groups on CE, the P1 group, with CCI or low initial Hb level, should be cautiously observed after the first bleeding episode.

Preparation, Timing, Prokinetics, and Surface Agents in Video Capsule Endoscopy

There is a trend in data to support active preparation for video capsule endoscopy (VCE), but the timing of this remains unclear. Split dosing may be the most efficacious preparation. Study methodology continues to evolve, with increased use of standardized scales, with the addition of diagnostic yield as an outcome. The use of adjuncts has not been detrimental, but their value has not been proved to improve outcomes of VCE.

A randomized controlled trial of high volume simethicone to improve visualization during capsule endoscopy

Background

The optimal dose of simethicone before capsule endoscopy is unknown. Prior studies have reported inconsistent cleansing, with some showing improved visualization only in the proximal small intestine. We hypothesized a higher volume of simethicone may improve cleansing and diagnostic yield, especially in the distal small bowel.

Methods

A phase III randomized controlled trial was conducted comparing high volume (1125 mg simethicone in 750 ml water) versus standard volume (300 mg simethicone in 200 ml water) solutions, both at 1.5 mg/ml. The primary outcome was adequate bowel preparation, defined as a KOrea-CanaDA (KODA) score >2.25, overall and stratified by the proximal and distal half of the small bowel. Secondary outcomes included mean KODA score, diagnostic yield, completion rate, and adverse events. All analyses were intention-to-treat.

Results

A total of 167 patients were randomized (mean (SD) age 58.7 (15.7), 54% female) and the most common indication was obscure gastrointestinal bleeding (71.7%). Adequate cleansing was achieved in 39 (50%) patients in the high volume group and in 39 (48%) patients in the standard volume group (RR 1.04, 95% CI 0.76–1.43, p = 0.82), with no differences observed in the proximal half (71% vs 64%, p = 0.40) or the distal half -of the small bowel (36% vs. 37%, p = 0.88). There was no differences in the mean (SD) KODA score (2.20 (0.41) vs. 2.18 (0.44), p = 0.73), diagnostic yields (53% vs. 56%, p = 0.71), or completion rates (both 95%). One adverse event, nausea, occurred in the control group.

Conclusion

High volume simethicone does not improve visualization during capsule endoscopy.

Clinical trial registration

Clinical trial:NCT02334631.

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.

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.

KODA score: an updated and validated bowel preparation scale for patients undergoing small bowel capsule endoscopy

Background and study aims  A reliable outcome measure is needed for bowel preparation quality during capsule endoscopy. Currently, no scales are adequately validated. Our objective was to update an existing small bowel preparation score, create a standardized training module, then determine its inter-rater and intra-rater reliability. Patients and methods  Modification to produce standardized scoring of an existing small bowel preparation score was performed followed by development of a training module and validation to create the new Korea-Canada (KODA) score. Twenty readers from a range of backgrounds, including capsule endoscopists, gastroenterology fellows, residents, medical students, and nurses rated bowel cleanliness in 25 capsule videos consisting of 1,233 images, in duplicate 4 weeks apart, after completing the training module. Sequential images selected in 5-minute intervals during small bowel transit were rated on a scale between 0-3 based on the amount of visualized mucosa and the degree of obstruction. Reliability was assessed using estimates of intraclass correlation coefficients (ICCs). Results  Intraclass correlation coefficients for inter-rater (ICC 0.81, 95 % CI 0.70-0.87) and intra-rater (ICC 0.92, 95 % CI 0.87-0.94) reliability were almost perfect among the 20 readers. Inter-rater reliability ranged between 0.72 (95 % CI 0.57-0.81) and 0.89 (95 % CI 0.79-0.93) for nurses and residents, respectively. Intra-rater reliability was greater than 0.90 for all groups except for nurses, which was still almost perfect (ICC 0.86, 95 % CI 0.79-0.90). Conclusions  Almost perfect inter-rater and intra-rater reliability was observed for the KODA score. This simple score could be used for future clinical trials after completion of the training module.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Low-dose and same day use of polyethylene glycol improves image of video capsule endoscopy: A multi-center randomized clinical trial

BACKGROUND AND AIM

Clear visualization of the small bowel is a requirement for satisfactory video capsule endoscopy (VCE). The aim of this study was to identify the optimal dose and timing of polyethylene glycol (PEG) for small bowel preparation before VCE.

METHODS

A total of 410 patients were enrolled in this prospective randomized trial. All patients fasted for 12 h and ingested 320 mg simethicone 30 min before swallowing the capsule. Patients were randomized into five groups: Group A (no PEG), Group B (1-L PEG, 12 h before VCE), Group C (2-L PEG, 12 h before VCE), Group D (1-L PEG, 4 h before VCE), and Group E (2-L PEG, 4 h before VCE). The primary endpoint was small bowel visualization quality (SBVQ), and the secondary endpoints were patient acceptability and diagnosis rate of VCE.

RESULTS

Excellent SBVQ was achieved in 27 (32.5%) of Group A, 38 (46.3%) of Group B, 40 (48.2%) of Group C, 55 (66.3%) of Group D, and 43 (54.4%) of Group E. The percentage of excellent SBVQ in Group D was significantly more than in Group A (66.3% vs 32.5%, P < 0.001), and diagnostic rate in the distal segment was higher (28.9% vs 10.8%, P = 0.0035). Patient acceptance of 1-L PEG was better than of 2-L PEG (P < 0.005).

CONCLUSION

Small bowel cleansing with 1-L PEG given 4 h before VCE was the optimal preparation for visualization of the bowel and patient acceptance (ClinicalTrials.gov, ID: NCT02486536).

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.

Analysis of small bowel angioectasia in asymptomatic individuals depending on patients' age and gender

Objectives: Small bowel angioectasia (SBA) plays an important role in the etiologies of obscure gastrointestinal haemorrhage. But the exact prevalence of the disease is unknown, especially in asymptomatic populations. Therefore, we aimed to evaluate the prevalence of asymptomatic angioectasia in the small bowel (SB) with magnetically controlled capsule gastroscopy (MCCG).Methods: We retrospectively collected a multicentre clinical data of 508 asymptomatic patients who underwent MCCG from June 2018 to May 2019. Bowel cleanliness was rated as four grades according to the criteria, and the excellent or good preparation was classified as the adequate group. The detection rates of small bowel lesions were analysed according to the ages, genders and bowel preparations.Results: A total of 508 individuals have completed the examination. There were 316 men and 192 women with an average age of 44.5 years old. The prevalence of SBA was 11.8% (95% CI: 9.0-14.6%). 70.0% of them were over 40 years old and 73.3% were male although there was no obvious disparity found in age and gender for the SBA. Most findings were located in the proximal small bowel (jejunum). The incidence of small bowel lesions was not related to bowel preparations (p > .05).Conclusions: SBA is not uncommon in asymptomatic individuals. Age and gender may be risk factors for bleeding of angioectasia in the small bowel, but they seem to have little to do with the occurrence of it. MCCG showed no difference in ages, genders or bowel preparations of small bowel lesions among our study population.

Current Controversies Concerning Capsule Endoscopy

Video capsule endoscopy became a reality in 2001. This device enabled us to directly view the mucosa of the small intestine for the first time. The main indications for the video capsule remain the detection of small intestinal bleeding and iron deficiency anemia, diagnosis and management of Crohn's disease, and detection of tumors. The device is extraordinarily safe and can be used in the very young to the very old. However, there remain several areas of controversy and difficulty. These are covered in this article and include details of indications and contraindications, whether to prepare patients, whether or not to use simethicone and prokinetics. Detection of location of the capsule remains a major engineering challenge. Reading the videos reliably and quickly remains challenging. However, artificial intelligence and machine learning are already on the horizon to provide assistance. New uses for capsule endoscopy promise more accurate diagnosis and hence improved management of acute gastrointestinal bleeding. The colon capsule may eventually help those who refuse conventional colonoscopy, and robotically controlled capsules may be helpful in screening for serious disease in patients with upper abdominal complaints. The advent of the broadening use of video capsule endoscopy is, though it will be controversial, embraced by some and derided by others; such is the nature of technological development. In the long run, if the use of the video capsule, based on sound evidence-based studies, can be shown to improve the care of our patients and reduce the cost of health care, its use will continue to expand.

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.

Evaluating a combined bowel preparation for small-bowel capsule endoscopy: a prospective randomized-controlled study

Background

Capsule endoscopy (CE) is frequently hindered by intra-luminal debris. Our aim was to determine whether a combination bowel preparation would improve small-bowel visualization, diagnostic yield, and the completion rate of CE.

Methods

Single-blind, prospective randomized–controlled study of outpatients scheduled for CE. Bowel-preparation subjects ingested 2 L of polyethylene glycol solution the night prior to CE, 5 mL simethicone and 5 mg metoclopramide 20 minutes prior to CE and laid in the right lateral position 30 minutes after swallowing CE. Controls had no solid food after 7 p.m. the night prior to CE and no liquids 4 hours prior to CE. Participants completed a satisfaction survey. Capsule readers completed a small-bowel-visualization assessment.

Results

Fifty patients were prospectively enrolled (56% female) with a median age of 54.4 years and 44 completed the study (23 patients in the control group and 21 in the preparation group). There was no significant difference between groups on quartile-based small-bowel visualization (all P > 0.05). There was no significant difference between groups in diagnostic yield (P = 0.69), mean gastric (P = 0.10) or small-bowel transit time (P = 0.89). The small-bowel completion rate was significantly higher in the preparation group (100% vs 78%; P = 0.02). Bowel-preparation subjects reported significantly more discomfort than controls (62% vs 17%; P = 0.01).

Conclusions

Combined bowel preparation did not improve small-bowel visualization but did significantly increase patient discomfort. The CE completion rate improved in the preparation group but the diagnostic yield was unaffected. Based on our findings, a bowel preparation prior to CE does not appear to improve CE performance and results in decreased patient satisfaction (ClinicalTrials.gov, No. NCT01243736).

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.

Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Development and validation of an automated algorithm to evaluate the abundance of bubbles in small bowel capsule endoscopy

BACKGROUND AND STUDY AIMS

Bubbles can impair visualization of the small bowel (SB) mucosa during capsule endoscopy (CE). We aimed to develop and validate a computed algorithm that would allow evaluation of the abundance of bubbles in SB-CE still frames.

PATIENTS AND METHODS

Two sets of 200 SB-CE normal still frames were created. Two experienced SB-CE readers analyzed both sets of images twice, in a random order. Each still frame was categorized as presenting with < 10 % or ≥ 10 % of bubbles. Reproducibility (κ), sensitivity (Se), specificity (Sp), receiver operating characteristic curve, and calculation time were measured for different algorithms (Grey-level of co-occurrence matrix [GLCM], fractal dimension, Hough transform, and speeded-up robust features [SURF]) using the experts' analysis as reference. Algorithms with highest reproducibility, Se and Sp were then selected for a validation step on the second set of frames. Criteria for validation were κ = 1, Se ≥ 90 %, Sp ≥ 85 %, and a calculation time < 1 second.

RESULTS

Both SURF and GLCM algorithms had high operating points (Se and Sp over 90 %) and a perfect reproducibility (κ = 1). The validation step showed the GLCM detector strategy had the best diagnostic performances, with a Se of 95.79 %, a Sp of 95.19 %, and a calculation time of 0.037 seconds per frame.

CONCLUSION

A computed algorithm based on a GLCM detector strategy had high diagnostic performance allowing assessment of the abundance of bubbles in SB-CE still frames. This algorithm could be of interest for clinical use (quality reporting) and for research purposes (objective comparison tool of different preparations).

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.

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.

Validation of the computed assessment of cleansing score with the Mirocam® system

BACKGROUND AND AIMS

A computed assessment of cleansing (CAC) score was developed to objectively evaluate small-bowel cleansing in the PillCam® capsule endoscopy (CE) system and to overcome the subjectivity and complexity of previous scoring systems. Our study aimed to adapt the CAC score to the Mirocam® system, evaluate its reliability with the Mirocam® CE system and compare it with three validated subjective grading scales.

PATIENTS AND METHODS

Thirty CE were prospectively and independently reviewed by two authors who classified the degree of small-bowel cleanliness according to a quantitative index, a qualitative evaluation and an overall adequacy assessment. The authors were blinded for the CAC score of each CE, which was calculated as ([mean intensity of the red channel]/[mean intensity of the green channel] - 1) x 10. The mean intensities of the red and green channels of the small-bowel segment of the "Map View" bar in the Miroview Client® were determined using the histogram option of two photo-editing software.

RESULTS

There was a strong agreement between both CE readers for each of the three subjective scales used. The reproducibility of the CAC score was excellent and identical results were obtained with the two photo-editing software. Regarding the comparison between the CAC score and the subjective scales, there was a moderate-to-good agreement with the quantitative index, qualitative evaluation and overall adequacy assessment.

CONCLUSIONS

CAC score represents an objective and feasible score in the assessment of small-bowel cleansing in the Mirocam® CE system, and could be used per se or as part of a more comprehensive score.

Systematic review and meta-analysis: is bowel preparation still necessary in small bowel capsule endoscopy?

INTRODUCTION

Optimal bowel preparation for small bowel capsule endoscopy(SBCE) is controversial. This meta-analysis aimed to investigate the effects of laxatives in SBCE.

METHODS

A comprehensive literature search was conducted for studies investigating the use of laxatives in SBCE. The primary outcome was diagnostic yield(DY) for SB findings; secondary outcomes SB visualization quality(SBVQ) and completion rate(CR). Pooled odds ratios(ORs) with 95% confidence intervals(CIs) and number needed to treat(NNT) were calculated.

RESULTS

Forty studies (4380 patients with laxatives, 2185 without) were included. Laxative use did not improve DY of SB findings overall (OR 1.11 (95%CI 0.85-1.44)) or for significant SB findings (OR 1.10 (95%CI 0.76-1.60)). However, SBVQ improved with the use of laxatives (OR 1.60 (95%CI 1.08-2.06)), NNT 14. The OR for completed SBCE was 1.30 (95%CI 0.95-1.78). Patients given polyethylene glycol(PEG) had lower DY than sodium phosphate(NaP). SBVQ improved more with NaP (NNT 7) than PEG (NNT 53).

CONCLUSIONS

Laxatives do not significantly improve DY or CR in SBCE, but do improve SBQV. The use of laxatives may be beneficial in patients likely to have subtle findings. There are significant differences in methodology/definitions between studies, hence the need for standardized visualization scoring and recording of SBCE findings.

Optimal use of polyethylene glycol for preparation of small bowel video capsule endoscopy: a network meta-analysis

OBJECTIVE

Standardized strategy of bowel preparation before video capsule endoscopy (VCE) remains controversial. This study aimed to assess the ideal dose of PEG, based on small bowel visualization quality (SBVQ), diagnostic yield (DY), and complete rate (CR) of VCE using a network meta-analysis (NMA) of randomized controlled trials (RCTs).

METHODS

This NMA included RCTs comparing any of the following bowel preparation interventions for VCE: fasting overnight ("Fast"), 1 liter PEG ("PEG 1L"), 2-liter PEG ("PEG 2L"), or 4-liter PEG ("PEG 4L"). The authors searched papers in PubMed, Cochrane Library, and Embase as of June 2016. The cumulative ranking (SUCRA) probabilities to rank different doses of PEG and Fast were used.

RESULTS

The search engine provided 102 studies. Nine RCTs including 982 patients were incorporated into this analysis. All studies showed low risk of bias of blinding. SUCRA provided an initial ranking among these strategies, in which PEG 2 L showed the best score in SBVQ (PEG 2 L, 89.4%; PEG 1 L, 62.5%; PEG 4 L, 44.0%; Fast, 4.1%) and DY (PEG 2 L, 74.6%; PEG 1 L 28.1%; PEG 4 L 65.9%; Fast 31.4%) of VCE. No significant difference was shown in the analysis of CR.

CONCLUSIONS

This study recommends PEG 2 L as the ideal dose, which may improve the SBVQ of VCE and, therefore, diagnostic accuracy. Multi-center randomized controlled trials are required to verify these findings.

Quality Indicators for Small Bowel Capsule Endoscopy

Capsule endoscopy (CE) enables evaluation of the entire mucosal surface of the small bowel (SB), which is one of the most important steps for evaluating obscure gastrointestinal bleeding. Although the diagnostic yield of SB CE depends on many clinical factors, there are no reports on quality indicators. Thus, the Korean Gut Image Study Group (KGISG) publishes an article titled, “Quality Indicators for Small Bowel Capsule Endoscopy” under approval from the Korean Society of Gastrointestinal Endoscopy (KSGE). Herein, we initially identified process quality indicators, while the structural and outcome indicators are reserved until sufficient clinical data are accumulated. We believe that outcomes of SB CE can be improved by trying to meet our proposed quality indicators.

NASPGHAN Capsule Endoscopy Clinical Report

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

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.

Simethicone residue remains inside gastrointestinal endoscopes despite reprocessing

BACKGROUND

During a study designed to assess endoscope reprocessing effectiveness, a borescope was used to examine lumens and ports. Cloudy, white, viscous fluid was observed inside fully reprocessed gastroscopes and colonoscopes. This fluid resembled simethicone, which is commonly administered to reduce foam and bubbles that impede visualization during gastrointestinal endoscopy. This article describes methods used to determine whether the observed fluid contained simethicone.

METHODS

Photographs of residual fluid were taken using a borescope. Sterile cotton-tipped swabs were used to collect samples of fluid observed in 3 endoscope ports. Samples were evaluated using Fourier transform infrared spectroscopy (FTIR)-attenuated total reflection analysis.

RESULTS

Residual fluid was observed inside 19 of 20 endoscopes. Fluid photographed in 8 endoscopes resembled simethicone solutions. FTIR analysis confirmed the presence of simethicone in 2 endoscopes.

CONCLUSIONS

Fluid containing simethicone remained inside endoscopes despite reprocessing. Simethicone is an inert, hydrophobic substance that may reduce reprocessing effectiveness. Simethicone solutions commonly contain sugars and thickeners, which may contribute to microbial growth and biofilm development. Studies are needed to assess the prevalence of residual moisture and simethicone in endoscopes and determine the impact on reprocessing effectiveness. We recommend minimizing the use of simethicone pending further research into its safety.

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.

Review of small-bowel cleansing scales in capsule endoscopy: A panoply of choices

Evaluation of the quality of small-bowel cleansing is required to assess the reliability of findings in capsule endoscopy (CE). Moreover, consensus regarding the need of intestinal preparation for CE remains to be achieved. The presence of multiple grading scales for small-bowel preparation in CE, which are time-consuming and complicated, adds difficulty to the comparison of different small-bowel cleansing regimens and their application in clinical practice. Nowadays, a validated scale universally accepted for grading small-bowel cleansing is lacking. In fact, there are numerous grading systems with very different technical characteristics, namely, the parameters and the portion of the CE video that are analyzed, the objectivity of the analysis, the lesser or greater dependency on the operator, and the validation of the score. The authors performed a review which aims to systematize and summarize currently available small-bowel grading scales in CE.

Application of simethicone combined with compound polyethylene glycol in bowel preparation before colonoscopy

AIM: To assess the application value of simethicone combined with compound polyethylene glycol in bowel preparation before colonoscopy.

METHODS: Six hundred and eighty-two patients who underwent colonoscopy at our hospital from January 2014 to December 2015 were selected. They were randomly divided into either an observation group or a control group according to the order of treatment. Patients in the control group were orally administered with polyethylene glycol electrolyte powder 6 h before colonoscopy, and patients in the observation group were orally administered with simethicone 4 h before colonoscopy and polyethylene glycol electrolyte powder 6 h before colonoscopy. Intestinal cleanliness, bubble-removing effect, duration of colonoscopy, abdominal pain, abdominal distension and other adverse reactions were compared between the two groups.

RESULTS: The rate of satisfying intestinal cleanliness were high in both groups, and there was no significant difference between the two groups (observation group 93.3% vs control group 90.0%, χ² = 2.316, P = 0.128). The rates of satisfying bubble removal and acceptable bubble removal and the rate of severe bubbles were 90%, 8.2%, and 2.8%, respectively, in the observation group, and the corresponding percentages in the control group were 86.5%, 7%, and 6.5%, and there were significant differences between the two groups (χ² = 9.690, P = 0.008). The average duration of colonoscopy was 11.6 min ± 3.1 min in the observation group, which was significantly lower than that of the control group (12.3 min ± 3.8 min, t = 2.636, P = 0.009). The rate of abdominal pain did not differ significantly between the two groups (χ² = 1.951, P = 0.163); but the incidence of abdominal distension was 10.6% in the observation group, which was significantly lower than that in the control group (χ² = 5.491, P = 0.019).

CONCLUSION: Application of simethicone combined with compound polyethylene glycol in bowel preparation for colonoscopy could obviously remove intestinal bubbles, improve the visualization, shorten the examination time, and reduce the incidence of abdominal distension.

Small bowel neuroendocrine tumors: From pathophysiology to clinical approach

Neuroendocrine tumors (NETs), defined as epithelial tumors with predominant neuroendocrine differentiation, are among the most frequent types of small bowel neoplasm. They represent a rare, slow-growing neoplasm with some characteristics common to all forms and others attributable to the organ of origin. The diagnosis of this subgroup of neoplasia is not usually straight-forward for several reasons. Being a rare form of neoplasm they are frequently not readily considered in the differential diagnosis. Also, clinical manifestations are nonspecific lending the clinician no clue that points directly to this entity. However, the annual incidence of NETs has risen in the last years to 40 to 50 cases per million probably not due to a real increase in incidence but rather due to better diagnostic tools that have become progressively available. Being a rare malignancy, investigation regarding its pathophysiology and efforts toward better understanding and classification of these tumors has been limited until recently. Clinical societies dedicated to this matter are emerging (NANETS, ENETS and UKINETS) and several guidelines were published in an effort to standardize the nomenclature, grading and staging systems as well as diagnosis and management of NETs. Also, some investigation on the genetic behavior of small bowel NETs has been recently released, shedding some light on the pathophysiology of these tumors, and pointing some new directions on the possible treating options. In this review we focus on the current status of the overall knowledge about small bowel NETs, focusing on recent breakthroughs and its potential application on clinical practice.

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.

Optimal Bowel Preparation for Video Capsule Endoscopy

During video capsule endoscopy (VCE), several factors, such as air bubbles, food material in the small bowel, and delayed gastric and small bowel transit time, influence diagnostic yield, small bowel visualization quality, and cecal completion rate. Therefore, bowel preparation before VCE is as essential as bowel preparation before colonoscopy. To date, there have been many comparative studies, consensus, and guidelines regarding different kinds of bowel cleansing agents in bowel preparation for small bowel VCE. Presently, polyethylene glycol- (PEG-) based regimens are given primary recommendation. Sodium picosulphate-based regimens are secondarily recommended, as their cleansing efficacy is less than that of PEG-based regimens. Sodium phosphate as well as complementary simethicone and prokinetics use are considered. In this paper, we reviewed previous studies regarding bowel preparation for small bowel VCE and suggested optimal bowel preparation of VCE.

Benefit of a 360-degree horizontal turn following premedication with simethicone on image quality during gastroendoscopy: a randomized controlled trial

OBJECTIVES

To investigate whether a 360-degree horizontal turn after oral premedication with simethicone improves the mucosal visibility during gastroendoscopic examination, and to determine the proper time to turn over the patient.

METHODS

This study involved 993 patients scheduled for gastroendoscopy. Just before gastroendoscopy, after oral premedication with simethicone, patients were randomly assigned to three groups: in Group A, patients waited for 20 min before gastroendoscopy; in Group B, patients were separately waited for 5/10/15/20 min and were then turned 360 degrees just before gastroendoscopy; in Group C, patients were immediately turned 360 degrees and then separately waited for 5/10/15/20 min before examination. The sum of the gastric mucosal visibility scores (MVS) was calculated after the examination. The MVS and proportion of images with higher visibility scores for the mucosal surface. Lower scores indicate better visibility of the mucosal surface.

RESULTS

In Groups B and Groups C, when waiting time more than 10 min had lower mean total MVS than Group A. The MVS of four subgroups of Group B were not different from those of Group C.

CONCLUSION

Oral premedication with simethicone and immediately make a body posture change (turning over 360 degrees) then waiting for 10min can increase the image quality during gastroendoscopy and effectively decrease the premedication time.

Simethicone adjunct to polyethylene glycol improves small bowel capsule endoscopy imaging in non-Crohn's disease patients

BACKGROUND

Currently, there is no standardized protocol for bowel preparation before small bowel capsule endoscopy (SBCE). This study aimed to investigate the effect of simethicone combined with polyethylene glycol (PEG) on the visualization quality (VQ) of the SBCE in patients with or without known or suspected Crohn's disease (CD).

METHODS

This observational, prospective, single-center study included consecutive patients undergoing a SBCE between 2007 and 2008. Patients received either a standard bowel cleansing preparation of 2 L PEG and 80 mg simethicone orally 12 and 1 h before SBCE respectively (Group A) or only PEG (Group B). VQ, based on scores for luminal bubbles in frames taken from the small intestine, examination completeness, SBCE diagnostic yield, gastric and small bowel transit times were recorded.

RESULTS

Of the 115 patients finally included (Group A, n=56 and Group B, n=59) the cecum was visualized in 103 (89.6%). Simethicone overall improved the VQ in the proximal [OR: 2.43 (95%CI: 1.08-5.45), P=0.032] but not in the distal bowel segment (P=0.064). Nevertheless, this effect was not observed in patients undergoing SBCE for either known or suspected CD.

CONCLUSION

Simethicone as an adjunct to PEG for bowel preparation in patients undergoing SBCE significantly improved the VQ in non-CD patients.