Capsule Endoscopy
Michel DELVAUX, Gérard GAY
Dept of Internal Medicine and Digestive Pathology
Hôpitaux de Brabois
CHU de Nancy, France
Endoscopy of the small bowel:
one decade of advances
CT
Capsule
Push enteroscopy
MRI
PPE
Pill Cam®
Given Imaging
Endo Capsule (Olympus)
Reading of the recordings
• Multi-viewing system®
– Reduces the reading time
– No influence on the results1
• Detector of red lesions
– Detection of «red» pixels
– Acceptable sensitivity but low
correlation with physician’s
selection of images 2,3
• Locating device
– Comparison of the signal
intensity at the various skin
electrodes
– Unprecise
– Limited clinical usefulness
1 SHREIBER et al. Gastrointestendosc 2003 ; 57 : 1864 (abstract)
2 LIANGPUNSAKUL et al. Gastrointestendosc 2003 ; 57 : 164 (abstract)
(abstract)
3 D’HALLUIN PN et al. Gastrointest. Endosc. 2005 ; 61: 243243-24
Olympus Endo capsule: reading software
Without Enhancement
With Enhancement
A different view of the gut wall
Unspecific findings and normal variants
White mucosa
(close view)
Intussusceptions
Submucosal veins
Procedure Description (Pill cam SB) :
The certainties
• Patients fasting from midnight
• Water drinking allowed two hours
and food, four hours after capsule
ingestion
• Gut cleansing?
– Yes, because better examination of
the mucosa, especially in the ileum1
– How?
• 2 L PEG the day before and 2 L in
the morning before capsule
ingestion?
– Does not allow a better examination of
the caecum and right colon
1
CORON E et al. 3rd ICCE, Miami 2004
CHONG A et al. Gastrointest Endosc 2004
BENSOUSSAN B et al. Endoscopy 2004
NIV Y. et al. Gastroenterology 2004
Description of the procedure: open issues
• Simethicone?
– No demonstrated efficacy
• Prokinetics?
– Erythromycin : 1 to 3 mg/kg = 250 mg orally or IV 1
• Increases gastric emptying, induces phases III of the MMC
• Does not significantly alter the intestinal transit time
• May be useful in case of gastroparesis
– Metoclopramide :
• No pharmacological basis
• Speeds up the duodenal transit of the capsule
• Who should read?
– Nurse Vs Experienced endoscopist = 96%
– Nurse may help to select images in emergency cases
– Experienced endoscopist reads faster and selects less irrelevant
images
1.
FIREMAN et al Gastrointest Endosc 2003
Recent technical improvements
Rapid View®
Indications
• Obscure digestive bleeding
– Overt bleeding / Occult bleeding
– Chronic anaemia
• Crohn’s disease
• Coeliac disease
• NSAIDs-related enteropathy
• Polyposis syndromes
• Tumours
Diagnostic Yield of VCE in Obscure Digestive
Bleeding
N
Controlled % Diagn. % Diagn. Conclusion
Study
VCE
VPE
Lewis
GI Endosc
21
Yes
55
30
VCE > VPE
Saurin, Delvaux
et al.
Endoscopy 2003
58
Yes
68
37
VCE > VPE
Ell et al.
Endoscopy 2002
39
Yes
66
28
VCE > VPE
Mylonaki et al.
Gut 2003
50
Yes
68
32
VCE > VPE
Pennazio et al.
Gastroenterology 29
2004
Yes
58.6
27.6
VCE > VPE
Van Gossum et
al.
Acta
Gastroenterol
Belg. 2003
21
Yes
10 gastric
lesions
62
51
VCE = VPE
Mata et al.
Aliment.
Pharmacol. Ther
2004
42
Yes
74
19
VCE > VPE
Meta-analysis of studies comparing VCE
and VPE
Triester et al. Am. J. Gastroenterol 2005
Diagnostic Yield of VCE according to
time of investigation
• Pennazio et al. Gastroenterology 2004
Influence of VCE results on
management of patients with obscure
digestive bleeding
N patients
Diagnostic Yield
of VCE
Therapeutic
Decision based
on VCE
Mata et al.
Aliment Pharmacol
Ther 2005
42
74 %
22 %
Neu et al.
Am J
Gastroenterol 2005
56
68 %
37.5 %
Ben Soussan E
et al.
Gastroenterol Clin
Biol 2004
35
45.7 %
37 %
Delvaux et al.
Endoscopy 2004
44
41.9 %
66 %
Moreno et al.
Acta Gastroenterol
Belg 2005
36
29 %
82 %
P2
P1
P0
Clinical Relevance of P2 lesions
34 Patients with intestinal lesions detected at the initial VCE
15 P2 lesions
10 treated
14 P1 lesions
1 patient with an other
source of bleeding
diagnosed afterwards
4 treated
P = 0.02
Saurin et al. Endoscopy 2005; 37: 318-323
5 P0 lesions
9 patients with an
other source of
bleeding diagnosed
afterwards
Indications
• Obscure digestive bleeding
– Overt bleeding / Occult bleeding
– Chronic anaemia
• Crohn’s disease
• Coeliac disease
• NSAIDs-related enteropathy
• Polyposis syndromes
• Tumours
Capsule endoscopy in Crohn’s disease
•
Methodological limits of available
studies1,2
•
VCE finds more intestinal lesions than
expected in patients with Crohn’s
disease2,3
•
No systematic indication in patients
with typical Crohn’s disease
1 Herreiras
JM et al. Endoscopy 2003
et al. Eur. J. Gastroenterol. Hepatol. 2002
3 Rodriguez-Tellez M et al. Endoscopy 2002
2 Eliakim
Diagnostic potential of VCE in Crohn’s
disease
• VCE influences the management of
the patients depending on the
clinical situation in up to 70 % of the
cases1
– Detection of early recurrences after
surgery2
77 % of 22 operated patients.
– Determination of cases with
unspecified colitis3
– Differential diagnosis
– Investigation of unexplained symptoms
1 Chong
AHK et al. Gastrointest Endosc 2005
A et al. Gastrointest Endosc 2005
3 Colombel JF et al. Endoscopy 2005
2 Boureille
Role of VCE in management of Crohn’s
disease
• Need for biopsies
– Association of VCE with Push-andPull enteroscopy
• Change in the therapeutic
approach
– Immunosuppresive therapy
– Endoscopic treatment of Intestinal
stenoses
• Risk of blockade of capsule
progression
– Radiological assessment
– Patency capsule
Role of VCE in Coeliac disease
• Good correlation between the
pattern of mucosa detected by VCE
and intestinal biopsies1,2
– Sensitivity 94.4
– Specificity 85.72
• Potential indications
– Patients with unexplained abdominal symptoms3
– Children with clinical or biological suspicion of
coeliac disease
– Evaluation of the response to a gluten-free diet4
– Screening?
– Chronic anaemia
– Surveillance5
1Krauss
NG et al. Gastrointest Endosc 2005
Franchis R et al. Gastrointest Endosc 2005
3 Gay et al. Gastrointest Endosc 2002
4Dubencenco E et al. Gastrointest Endosc 2005
5Apostolopoulos P. et al., Endocopy 2004
2de
Some further indications…
• Malabsorption Syndromes…
• Diffuse intestinal diseases…
Amyloidosis
Whipple
Exsudative enteropathy
Eosinophilic gastro-enteritis
Indications
• Obscure digestive bleeding
– Overt bleeding / Occult bleeding
– Chronic anaemia
• Crohn’s disease
• Coeliac disease
• NSAIDs-related enteropathy
• Polyposis syndromes
• Tumours
VCE for diagnosis of intestinal tumours
• VCE shows that intestinal
tumours are more frequent
than expected
– 8.5 % of patients with ODB1
– 11.7 % of 291 patients with ODB
(personal data)
• VCE changes the picture of
intestinal tumours:
– VCE allows an earlier diagnosis
of intestinal tumours
– Frequency of histological types
is modified
• GIST and adenocarcinomas
– Possibility of endoscopic
resection with push-and-pull
enteroscopy
1
Lewis BS, ICCE 2004
48 patients
with an Intestinal Tumour
GIST
ADK
T-cell
Adenoma
Lipoma
Carcinoid
Metastases
Haemangioma
Miscellaneous
VCE in Familial Polyposis
Syndromes
Surveillance of hereditary polyposis syndromes
– FAP : Familial adenomatous Polyposis
– PJS : Peutz-Jeghers Syndrome
– FJP : Juvenile Familial Polyposis
SCHULMAN K et al Gastrointest Endosc. 2003
VARADARAJULU S et al. Gastrointest. Endosc. 2004
CASPARI R. Endoscopy 2004
20 patients
FJP = 4
FAP = 16
In 8 patients VCE showed 448 polyps of 1 to 3 mm
In 4 patients MRI 24 polyps > 5 mm
Surveillance of HNPCC (Lynch)
- Not validated
- Schulman, Gastrointest. Endosc. 2005
Tolerance of SB Pill Cam
• Interference with pace-makers and
other stimulators: no longer a
contraindication1
• Capsule retention
– Mainly related to transit issues
•
•
•
•
1LEIGHTON
Delayed gastric emptying
Motility disorders
Zencker’s diverticulum
Anatomical stenoses
et al. Gastroenterology 2003
Frequency of Capsule Retention
• Frequency of capsule retention
– Obscure digestive bleeding
1089 pts
1.5 %
250 pts
1.4 - 5 %
1696 pts
1.8 %
937 pts
0.8 %
• Barkin and Friedman, Am. J. Gastroenterol. 2002
• Pennazio et al. Gastroenterology 2004
• Sears et al. Gastrointest. Endosc. 2004
– Crohn’s disease
•
•
•
•
Mow et al. Clin. Gastroenterol. Hepatol 2004
Buchman et al Am. J. Gastroenterol 2004
Fireman et al. Gut 2003
Herrerias et al. Endoscopy 2003
– Rösch T, Ell C et al.
• Z. Gastroenterol 2004
• Surgical indication for capsule retention
– Barkin JS, Friedman S
• Am J Gastroenterol 2002; 97: S298
How can a stenosis be detected before
a capsule procedure?
• Patient’s history
– Surgeries
– NSAIDs use
– Obstructive symptoms
• Radiological assessment
– Small bowel follow-through
– Entero-CT, Entero-MRI
– Abdominal ultrasound
• Nature of the suspected disease
No indicator with significant
PPV / NPV
The AGILE Patency Capsule
Parylene
Coating
Lactose Body w/ Barium
Exposed
windows
Timer Plugs
RFID tag
Patency Capsule
Disintegration and Terminology Post Excretion
g
Plu
dy
o
B
g
Plu
Intact Capsule
Intact Body
Disintegrating Body
Empty Shell and Tag
Body and Plugs
are virtually intact
Body is intact
and hard. Plugs
have eroded.
Body is losing its
original dimensions
and becomes soft
Capsule contents
have disintegrated
9
Patency capsule : Results
• 12 patients with
known stenoses
• 4 patients had pain
• 1 patient operated
for capsule
impaction
• 7 OK
• Our experience
– 22 patency capsules :
•
•
•
•
10 Crohn
5 Tumours
5 Suspicion of Crohn
2 NSAIDs
– 6 patients with severe
abdominal pain
• All had Crohn’s disease
– 4 prolounged retention
• 2 resolving
spontaneously
• 2 surgeries for
permanent occluion
BOIVIN ML et al Endoscopy 2005
GAY G et al Endoscopy 2005
Second example of blockade
Gay et al. Endoscopy 2005; 37: 174-7
Perspectives in Capsule Endoscopy
• Combination with push-and-pull
enteroscopy
– PPE allows:
•
•
•
•
Biopsies
Treatment of AVMs
Dilatation of stenosis
Removal of polyps and
tumours
– VCE helps to manage
patients undergoing a PPE
• Selection of indications
• Selection of the route of
insertion of the endoscope
Time Index for determining the location of the
lesions
Transit time
Transit time
lesion
caecum
PPE Anal route
≥ 0.75
Time Index Lesion/Caecum - min)
1
0.9
0.8
0.7
0.6
PPV = 94.7 %
NPV = 96.7 %
0.5
0.4
Oral route
0.3
0.2
Anal route
0.1
0
0
50
100
150
200
250
Time to the lesion (min.)
300
350
400
Perspectives in Capsule Endosocpy (2)
Oesophageal Capsule
Capsule with double optical system
to examine the oesophagus
– Battery lifetime = 1 hour
– Oesophageal transit time: 15s to
17min
– Patient in supine position
– Lesions observed : oesophagitis,
Barrett’s oesophagus, varices
– 17 patients Oeso CVE before OGD,
blinded reading: PPV 100%, NPV
92%
– Cost = around 400 USD
– Clinical use?
ELIAKIM RR et al. Gastrointest Endosc 2004
In the future…
• Examination of other parts of the gut
– Colon: Trial starting in Europe in 2006
– Stomach: Trial starting in the USA in 2007
• Control of progression of the capsule
• Drug release or succion biopsy ?
Capsule container
(11X33)
PILLCAM (11X33)
FRITSHER A Gastrointest Endosc 2005
Flexible plastic bond
Conclusion
• Capsule endoscopy has
changed the approach of
intestinal diseases:
– More frequent and earlier diagnosis
– New insights in the natural course
of the diseases
• Capsule endoscopy does not
replace conventional endoscopy
but complements it
• In the future, indications might
extend outside the small bowel