Indications for capsule endoscopy.
1. Introduction
2. Historical aspects of capsule endoscopy
In science, what is fiction today, may become reality tomorrow. This is amply documented once again by discovery of capsule endoscopy. Capsule endoscopy is a combination of the device that physicist G. Iddan had developed and that devised by Paul Swain.[2], [3] This was an attempt to reproduce the movie fiction filmed by R. Fleischer in 1966, based on a story by I. Asimov.[2] The first reported use of capsule endoscopy in ten human volunteers was published in 2000 by P. Swain in Nature.[1] The first model of capsule endoscopy was made available by Israeli Company Given Imaging by the name of M2A. Within a year of first publication, the capsule endoscopy was approved by US Food and Drug Administration.[4] Subsequently, it has been widely used throughout the World for diagnosis of small bowel diseases.
3. Small bowel capsule endoscopy: The method
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Small bowel | |
Obscure gastrointestinal bleeding (overt and occult) | |
Chronic small bowel diarrhea including celiac disease | |
Abnormal small bowel imaging | |
Chronic abdominal pain with reasonable suspicion of organic cause in the small intestine | |
Evaluation of Crohn disease and its extent | |
Visualization of surgical anastomosis | |
Suspected small bowel tumor | |
Polyposis syndrome | |
Portal hypertensive enteropathy and small intestinal varices | |
Esophagus | |
Barrett esophagus | |
Esophageal varices | |
Colon | |
Colon polyps and colorectal cancer |
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Length in mm | 26 | 26 | 26 | 24 | 26 | 27.9 |
Weight (g) | 3.4 | 3.4 | 3.4 | 3.4 | 3.8 | 6 |
Number of cameras | 1 | 2 | 2 | 1 | 1 | 1 |
Frame rate per second | 2 | 18 | 4-35 | 3 | 2 | 2 |
Image sensor | CMOS | CMOS | CMOS | CCD | CCD | CCD |
Battery life (h) | 8 | 8 | 8 | 11 | 9 | 8 |
Antennas | 8 | 3 | 8 | 9 | 8 | 14 |
Sleeping mode | No | No | Yes | No | No | No |
Other diseases of small bowel in which capsule endoscopy is indicated are summarized in Table 1. However, capsule endoscopy done in some of these conditions has limitations. For example, in celiac disease,[30] taking biopsy is very important to detect villous atrophy. However, in other conditions such as Crohn disease, small intestinal tumor, polyposis syndrome and portal hypertensive enteropathy and varices, capsule endoscopy is useful.[31]-[36] In endemic areas, hookworm infestation is not uncommonly detected in patients undergoing capsule endoscopy for obsure gastrointestinal bleeding.[27], [37], [38] Fig. 2 (A to F) and 3 (A to F) depict some of these findings on capsule endoscopy. Fig. 4 outlines a practical approach to use various small bowel endoscopic techniques in patients with obscure gastrointestinal bleeding.
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Albert JG et. al.[55] | England | 2008 | 285 | OGIB | 76.8% |
Almeida N[56] | Australia | 2009 | 15 | Severe overt OGIB | 73.3% |
Apostolopoulos P[57] | Germany | 2006 | 51 | Occult OGIB | 57% |
Apostolopoulos P[58] | United States | 2007 | 37 | Acute mild-to-moderate OGIB | 91.9% |
Ghoshal UC[27] | India | 2011 | 86 | Occult and overt OGIB | 74.4% |
Ben Soussan E[59] | France | 2004 | 35 | OGIB overt (n=17) and occult (n=18) | 45.7% |
Bresci G[60] | Japan | 2005 | 64 | OGIB | 62.5% |
Calabrese C[61] | Italy | 2011 | 346 | OGIB | 71% |
Carey EJ[26] | Unites States | 2007 | 260 | OGIB overt (n=126) and occult (n=134) | 53% |
Carlo JT[62] | United States | 2005 | 532 | 532 studies for OGIB | 49.3% |
Chao CC[63] | China | 2005 | 35 | OGIB | 89% |
Chong AK[64] | Australia | 2003 | 47 | OGIB | 68% |
De Leusse A[65] | Germany | 2005 | 64 | 64 OGIB (overt 69% and occult 31%) | 45% |
Gupta R[25] | India | 2006 | 154 | OGIB (overt 74, occult 80) | 51% |
Enns R[66] | Canada | 2004 | 167 | 167 studies, 88 overt, 79 occult) | 50.8% |
Estevez E[67] | England | 2006 | 100 | OGIB (overt 52, occult 48) | 68% |
Fireman Z[68] | England | 2004 | 160 | OGIB | 57.7% |
Fireman Z[69] | Israel | 2004 | 293 | OGIB | 72% |
4. Contraindications of capsule endoscopy
Contraindications of capsule endoscopy include suspected intestinal stricture (in which patency capsule may be used to evaluate tightness of the stricture),[39] cardiac pacemaker (recently capsule has been found safe and Capsovision type of capsule is quite safe),[40], [41] gastroparesis and esophageal motility disorders (capsule can be endoscopically delivered in the small bowel).[27] Even if capsule gets retained in stricture, it can be retrieved by single balloon and double balloon enteroscopy. Moreover, precipitation of small bowel obstruction by retained capsule is rare.[27] Pregnancy is also a contraindication to capsule endoscopy.
5. Complications of capsule endoscopy
Capsule retention is considered as a complication of capsule endoscopy. Capsule retention is defined as having a capsule remain in the digestive tract for a minimum of two weeks. Frequency of capsule retention in various studies varies from 0-13%.[42], [43] In a large series of 900 patients undergoing capsule endoscopy for obscure gastrointestinal bleeding, seven (0.77%) had capsule retention.[43] Interestingly, six of these seven patients had retention in spite a normal barium series. Several subsequent studies showed that normal barium does not prevent possible capsule retention.[27] Hence, a barium small bowel series is not indicated before capsule endoscopy. Moreover, yield of small bowel barium series is low to pick up causes of obscure gastrointestinal bleeding.[23] In an attempt to prevent capsule retention, patency capsule has been developed. This self-dissolving capsule (Fig. 1) of size same as endoscopy capsule, consists of a cellophane-walled cylinder filled with lactose and 10% barium for radio-opaqueness.[42] It is protected by wax plague at one end with a hole that allows influx of small bowel fluid, which dissolves lactose within 5 days. The patency capsule also has a transpoder device inside that helps in its detection using a hand-held scanner placed close to anterior abdominal wall.[42] However, the patency capsule can itself gets impacted in small bowel stricture.[44] Hence, it may not be entirely safe. Moreover, it increases the cost of capsule endoscopy. Hence, it has been suggested that obtaining a good medical history is the best method to avoid capsule retention.[44] Moreover, even if capsule gets retained, which occurs infrequently, precipitation of clinical obstruction is further uncommon. The retained capsule can be retrieved using balloon enteroscopy. Surgical removal, if needed, not only allows retrieving the capsule but also removes the pathology that led to capsule retention.
6. Esophageal and colon capsule endoscopy
Table 2 summarizes technical differences between esophageal and small bowel capsule endoscopy. Initial studies on esophageal capsule endoscopy did not find it very rewarding for detection of esophageal varices and Barrett esophagus in comparison to conventional esophagogastroduodenoscopy.[45], [46] Subsequently, string-controlled esophageal capsule endoscopy was tried to overcome some of the limitations.[47] However, it has to be noted that esophageal capsule endoscopy is expensive as compared to conventional esophagogastroduodenoscopy, will not have therapeutic potential and is not maneuverable. Hence, esophagogastroduodenoscopy remains the modality of choice for screening for Barrett’s esophagus.[48]
Table 2 summarizes technical specifications of colon capsule endoscopy. Colon capsule endoscopy may score over conventional colonoscopy as it will reduce patients discomfort and need for sedation. However, its efficacy for colon cancer screening, which is likely to be its major indication,[49] remains to be proved in large studies though a few meta-analysis have been reported.[50], [51] If it is effective, it may be useful to improve compliance with colorectal cancer screening. However, this technology is currently only a diagnostic method, any positive finding requires conventional colonoscopy for tissue sampling or polypectomy. There is currently no video capsule device cleared by the US Food and Drug Administration for dedicated colon imaging. This technology requires more research before it can become clinically applicable as standard of care.
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