Capsule Endoscopy
in Tamworth
True or False: “Capsule
Endoscopy is a useful test
in the diagnosis of
unexplained anaemia”
FALSE
Importance of Pre Test Probability

MBS – Item Number 11820

obscure gastrointestinal bleeding, using a capsule endoscopy device approved
by the Therapeutic Goods Administration (including administration of the capsule,
imaging, image reading and interpretation, and all attendances for providing the service
on the day the capsule is administered), (not being a service associated with double
balloon enteroscopy), if:
 (a) the service is performed by a specialist or consultant physician with
endoscopic training that is recognised by The Conjoint Committee for the
Recognition of Training in Gastrointestinal Endoscopy; and
 (b) the patient to whom the service is provided:
(i) is aged 10 years or over; and
(ii) has recurrent or persistent bleeding; and
(iii) is anaemic or has active bleeding; and
 (c) an upper gastrointestinal endoscopy and a colonoscopy have

been performed on the patient and have not identified the cause of
the bleeding; and
(d) the service is performed within 6 months of the upper
gastrointestinal endoscopy and colonoscopy
Understanding the “O’s” of GI
Bleeding

Obscure
Cause not identified
Inpractice,
obscureafter
GI endoscopies
bleeding is either
(up to10% - 75% will be due to small bowel lesions)
overt or causes iron deficiency
 Overt


Melaena or haematochezia
Occult

Not Overt
Diagnosing Iron Deficiency
Iron
Deficiency
↓
Systemic
Disease
↓
Mixed
Transferrin
↑
↓
↓
Transferrin
Saturation
Ferritin
↓↓
↓/N/↑
↓
↓
↑
↓/N/↑
Transferrin
Receptor
↑
N
↑
Iron
↓
Initial Iron Deficiency Workup

Consider ExtraIntestinal Causes
Dietary
 Pregnancy, Lactation
 Menstruation
 Haemolysis
 Blood donation
 Haematuria

Initial Iron Deficiency Workup


Consider ExtraIntestinal Causes
Gastroscopy
Ulcers, Malignancy, Angioectasia, GAVE
 H. Pylori status
 Duodenal biopsies for coeliac disease


Colonoscopy
Malignancy, colitis, angioectasia, proctitis
 Include ileoscopy
 Good bowel preparation important

Initial Iron Deficiency Workup

If Endoscopies are non-diagnostic:
Reconsider extraintestinal causes
 Consider Urinalysis and Coeliac disease serology


Iron Replacement OR Early Capsule Endoscopy
Iron Replacement OR
Early Capsule Endoscopy

Iron Replacement






Early Capsule Endoscopy
Younger
Premenopausal
Asymptomatic
Never overt bleeding

Observe for at least 3
months then recheck Hb
and ferritin. If “recurrent
or persistent bleeding”,
then capsule endoscopy




Older
Male
Symptoms, Weight loss
Any overt bleeding
Need to demonstrate
“recurrent or persistent
bleeding” – eg 2 low Hb’s,
a positive FOBT after
endoscopies etc
Capsule Endoscopy Preparation

Similar to colonoscopy
Stop iron tablets 5 days prior
 Clear fluids afternoon before
 2 sachets of PicoPrep
 10 hour fast


On the day

Metoclopramide and simethicone
What Does Capsule Endoscopy Visualize in
the Small Bowel?
Melanoma
Overt bleeding
Angioectasia
Mass/tumor
Inflammation by infection
(eg, CMV)
Ulcerated stenosis caused by
NSAID use
Inflammatory
stenosis
Bleeding ulcer
Yield of Capsule Endoscopy



38 – 83%
Depends largely on pre test probability
Of small bowel lesions found:
60% angioectasia
 30% ulcers / erosions
 10% tumours

Other Diagnostic Options
Method
Standard
Radiological Imaging
Bleeding Scan
Diagnostic Yield
• Low: 5% (unable to
diagnose most vascular
lesions)
• Low: ~25%
• Location accuracy:
~30–50%
Angiography
Double-Balloon
Enteroscopy
• Low: 25%–30%
• 60%–80%
Considerations
• Impact on management: <10%
•Useful for clinical suspicion of small bowel
obstruction, tumors
•
•
•
•
Sensitivity threshold: 0.3 mL/min
Prerequisite to angiography
Time-consuming
Little or no benefit in typical OGIB
• Sensitivity threshold: 0.5 mL/h
• Invasive
• Identifies bleeding/non-bleeding lesions
• Time-consuming
• Requires extensive training; additional
nursing staff, anesthesiological support often
required
• Optimal patient selection required
Diagnostic Options (continued)
Method
Diagnostic Yield
Considerations
Intraoperative
Enteroscopy
• 70%–100%
•
•
•
•
•
CT Enterography
• Low: vascular
• ~20% of submucosal lesions missed
Transfusion-dependent (severe blood loss)
Risk of continued bleeding (outweighs risk of therapy)
Technically difficult
Adhesions, luminal blood, infiltrating neoplasia
Complications (during and after procedure)
malformations,
ulcerative disease
Push
Enteroscopy
• 15%–35% average
• Variable for overt
• May detect missed proximal lesions
• Provides opportunity to identify and treat active
bleeding and AVMs:
5%–65%
Small Bowel CE
• 38%–83%
bleeding (AVMs only) 25%– 85% of the time within a
single year
• Affects change in management in ≥87% of patients
•
(50%–66% remain transfusion-free)
Low re-bleeding rates in patients with negative findings
of CE (5.6%–11%)
Complications Of Capsule
Endoscopy

Failure to enter the small bowel



Failure to visualise all small bowel



Dyspahgia, Gastroparesis
Can insert endoscopically
10-16%
Diabetics
Capsule Retention



<1% for OGIB, up to 10% for Crohn’s disease
Caution with previous small bowel surgery or abdominal
radiotherapy or clinical suspicion of obstruction
DBE or surgery to remove capsule +/- resect lesion
What to do with the Result




Negative : Observe unless symptoms suggest further
investigation
Tumours : Consider resection
Ulcers : Stop aspirin/NSAIDs, consider Crohn’s
disease
Angioectasia :



Reassurance and Iron Replacement (safest)
Assess antiplatelet agents or anticoagulants
If not controlled with iron, or intolerant of iron, then
consider ablative therapy
Via Gastroscopy,
Enteroscopy
or Colonoscopy
Patient
Histology
Capsule Endoscopy Quartile
Surgical Quartile
1
Carcinoid
4
4
2
Adenocarcinoma
4
4
3
Adenocarcinoma
1
1
4
Gastrointestinal
Stromal Tumour
3
2
5
Adenocarcinoma
1
1
6
Cavernous
Haemangioma
2
3
7
Lymphoma
1
1
8
Gastrointestinal
Stromal Tumour
3
2
9
Adenocarcinoma
4
4
10
Gastrointestinal
Stromal Tumour
2
1
11
Hyperplastic polyp
1
1
12
Cavernous
Haemangioma
3
2
13
Ectopic Pancreas
3
2
Identical quartile in 7/13
Different quartile by one in 6/13
350
Anterograde Push Enteroscopy
324
300
250
Angioectasia
Number
200
164
Red Spot
Ulcer
150
Tumour
105
104
100
58
57
57
47
50
28
16
10
5
15
2
2
1
0
1
3
2
Quartile
4
Other indications for Small Bowel
Capsule Endoscopy




Peutz-Jager syndrome
Crohn’s disease*
Coeliac disease*
Abnormal SB radiology*
* Not medicare rebateable
Other Types of Capsules

Patency Capsule

Oesophageal Capsule

Colonic capsule
So how do I get one?



Refer for a consultation
OR
Fax information across and I can have a look
OR
Refer directly yourself
Questions?