Video Capsule Endoscopy
Cem KALAYCI
Marmara University
Head, Dept. of Gastroenterology
ESGAR, Istanbul 2008
Small Intestinal Capsule
Comparative Capsule Designs
VCE
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PillCam (PillCam SB). (Given Imaging;
Yoqneam, Israel): FDA Approval 2000.
EndoCapsule (Olympus): FDA Approval
2007
Similar characteristics to the PillCam SB
but has a CCD chip instead of a CMOS
chip.
Given vs Olympus
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51 patients with obscure GI bleeding
PillCam SB and the EndoCapsule 40
minutes apart in randomized order
Similar results for normal and
abnormal
Gastrointest Endosc 2007; 65:AB125.
CAPSULE ENDOSCOPY
The Diagnostic Process
Technics
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Two images per second
55,000 images over eight hours.
Magnification 1:8
Review of the video, generation of a
report: 30 to 90 minutes.
Viewing: 1-25 frames per second
(standard video speed).
Primary Indications
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Obscure gastrointestinal bleeding
Suspected Crohn's disease
Small bowel tumors
Gastric Antral Vascular Ectasia
(GAVE)
Angioectasia in Ileum
Aphthous Ulcers
Crohn’s Disease: Ulcers
Crohn’s Disease: Edema
Crohn’s Disease: Strictures
Gastrointestinal Stomal
Tumors (GIST)
Other Indications
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NSAID injury to the small bowel
Abdominal pain (functional vs organic)
Celiac disease
NSAID Ulceration
NSAID Stricture/Webs
Celiac Disease
Additional Applications
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Small bowel polyps
Rejection in small bowel transplantation
GVH diseaase after bone marrow
transplantation
Surveillance of patients with hereditary
polyposis syndromes.
Advantages
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Noninvasive
Examination of the majority of the small
bowel mucosa, which is not possible with
push enteroscopy
Small bowel series, enteroclysis, and intraoperative enteroscopy are capable of
examining the entire length of the small
bowel, they are either quite insensitive or
invasive.
Disadvantage

No tissue sampling or therapeutic
intervention.
Obscure Bleeding
Obscure Bleeding
(100 patients)
n
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Ongoing overt bleeding
Previous overt bleeding
FOBT + and IDA
Pennazio et al, Gastroenterology
2004;126:643.
26
31
43
Pos.Study
(%)
92
13
44
MOST COMMON FINDINGS
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Angioectasia (29 percent)
Crohn's disease (6 percent).
Diagnostic yield is highest when performed as
close as possible to the bleeding episode.
Pennazio et al, Gastroenterology
2004;126:643.
Obscure Bleeding
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Sixty-two patients underwent further
examination that led to independent
verification of the diagnosis in 56.
Sensitivity: 89 %, Specificity: 95 %
PPV: 97 % NPV: 83 %
Ongoing obscure bleeding (overt or occult)
are the best candidates
Pennazio et al, Gastroenterology 2004;126:643.
Push Enteroscopy in the
Diagnosis of Obscure GI
Bleeding
Yield in Obscure bleeding
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A meta-analysis of 14 studies:
Capsule endoscopy: (63 percent)
Push enteroscopy (26 percent),
Barium studies (8 percent)
Triester, SL et al. Am J Gastroenterol 2005;
100:2407.
VCE vs SBFT
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22 patients suspected of having small bowel
pathology, underwent both VCE and SBFT.
Diagnostic study:
VCE: 45 %
SBFT: 20 %
Finding the cause of Obscure bleeding:
VCE: 31%
SBFT: 5 %
Costamagna, G, et al. Gastroenterology 2002;123:999.
Hadithi M, et al. Am J Gastroenterol 2006:100 :1-6
VCE vs DBE
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Diagnosing the etiology:
VCE: 80 % DBE: 60 %
A procedure/treatment was performed in
77 % of the patients with DBE
74 % of the patients remained stable
during 5 month follow up
Hadithi M, et al. Am J Gastroenterol 2006:100 :1-6
Crohn’s Disease
Crohn’s Disease
Crohn’s
Suspected CD
n
22
21
VCE Push
17
3
4*
0
Entero
4
1 (false)
*2 were false diagnosis
Chong et al, Gastrointest Endosc 2005;61:255-61
Crohn’s Disease
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VCE detected more erosions than push
entero and enteroclysis (p<0.001)
There was no difference in patients with
suspected Crohn’s disease.
Capsule endoscopy had a higher yield than
push enteroscopy and enteroclysis in
patients with known Crohn's disease
Chong et al, Gatsrointest Endosc 2005;61:255-61
Marmo, R, et al. Clin Gastroenterol Hepatol 2005; 3:772.
Video Capsule Endoscopy and
the Diagnosis of Suspected
Crohn’s Disease
VCE vs Barium in suspected
Crohn’s recurrence
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Studies produced complementary
results
VCE: Mucosal disease in six patients
with a normal SBFT
SBFT: Grade 1 mucosal disease in five
patients with a normal VCE study.
Buchman, AL, et al. Am J Gastroenterol 2004;
99:2171.
Risk: Retention of the capsule
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Clinically important retention < 1 %.
Patients with increased risk
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known or suspected Crohn's disease
intermitent SB obstruction secondary to adhesions
radiation enteritis
severe motility disorders
Zenker's diverticulum.
A normal barium study or CT scan does not
exclude the possibility of retention.
Capsule Retention
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Palpation by the surgeon of the capsule
retained above a stricture may be helpful in
localizing the stricture, which may have no
serosal signs, thus avoiding the need for
intra-operative enteroscopy.
Removal of the retained capsule by double
balloon enteroscopy has also been described
Patency capsule
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Same size as the PillCam
Composed of lactose and barium
Contains a radiofrequency identification
tag that allows it to be detected by a
scanning device
Dissolves in 40 to 80 hours after
ingestion.
Patency capsule
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To assure small bowel patency before VCE
Diagnostic test for suspected small bowel
strictures that cannot be identified by
standard radiographic means.
25 percent of patients with strictures
developed abdominal pain, some severe,
and two patients required emergency
surgery
Delvaux, M, V, et al. Endoscopy. 2005;
37:801.
Contraindications
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Dementia
Gastroparesis (the capsule can be
placed in the duodenum by endoscopy)
Esophageal stricture, swallowing
disorders (eg, Zenker's diverticulum)
(endoscopic placement)
Contraindications
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Partial or intermittent small bowel obstruction
Those who are inoperable or refuse surgery
Patients who have defibrillators or
pacemakers. This is a recommendation in the
package insert, but does not appear to be a
significant clinical problem.
Thank you.....
OGIB:VCE Prior to Push
Enteroscopy (PE)
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89 patients
VCE before PE is a more effective strategy
than beginning with push enteroscopy
12 months follow up
VCE first followed by PE vs PE followed by
VCE as needed had similar diagnostic yields.
VCE first strategy reduced the percentage of
patients needing the alternative study (25%
vs 79%).
de Leusse, A, et al. Gastroenterology 2007;
132:855.
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We suggest proceeding directly with VCE in
those in whom EGD and colonoscopy have
been unrevealing. Preliminary evidence
suggest a higher diagnostic yield in those
studied with recent bleeding. (See "Efficacy"
above).
In those in whom a lesion is detected within
reach of the push enteroscope, we suggest
proceeding with push enteroscopy with the
intention of treating or tattooing the lesion
(or both).
Treatment is more difficult in those with a
Normal Variants: Pylorus
Barrett’s Esophagus
Occult GI Bleeding)
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More effective than push
enteroscopy
Finding the cause 50-70 %
Gastrointest Endosc 2002;56:349,
2002;55AB88, AB128
Am J Gastro 2002;97:S299, 2002;97:S299
Endoscopy 2002;34:685 Gut 2003;52:1122,
Gastrointest Endosc 2004;59:492,
APT2004;20:189
Radiation Injury