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Capsule Endoscopy
Michel DELVAUX, Gérard GAYDept of Internal Medicine and Digestive Pathology
Hôpitaux de BraboisCHU de Nancy, France
Endoscopy of the small bowel:one decade of advances
Capsule
PPE
CT
MRI
Push enteroscopy
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 1 SHREIBER et al. Gastrointestendosc 2003 ; 57 : 1864 (abstract)SHREIBER et al. Gastrointestendosc 2003 ; 57 : 1864 (abstract)
22 LIANGPUNSAKUL et al. Gastrointestendosc 2003 ; 57 : 164 (abstrLIANGPUNSAKUL et al. Gastrointestendosc 2003 ; 57 : 164 (abstract)act)33 DD’’HALLUIN PN et al. Gastrointest. Endosc. 2005HALLUIN PN et al. Gastrointest. Endosc. 2005 ; 61: 243; 61: 243--2424
Olympus Endo capsule: reading softwareWithout Enhancement
With Enhancement
A different view of the gut wall
Unspecific findings and normal variants
Submucosal veinsIntussusceptionsWhite mucosa(close view)
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 2004CHONG A et al. Gastrointest Endosc 2004BENSOUSSAN B et al. Endoscopy 2004NIV 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 improvementsRapid 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
VCE > VPE1974Yes42Aliment. Pharmacol. Ther 2004
Mata et al.
VCE = VPE5162Yes10 gastric
lesions
21Acta Gastroenterol Belg. 2003
Van Gossum et al.
VCE > VPE27.658.6Yes29Gastroenterology 2004
Pennazio et al.VCE > VPE3268Yes50Gut 2003Mylonaki et al.
28
3730
% Diagn.VPE
66
6855
% Diagn.VCE
VCE > VPEYes39Endoscopy 2002Ell et al.
VCE > VPEYes58Endoscopy 2003Saurin, Delvaux et al.
VCE > VPEYes21GI EndoscLewis
ConclusionControlled Study
N
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
22 %74 %42Aliment Pharmacol Ther 2005Mata et al.
37 %45.7 %35Gastroenterol Clin Biol 2004
Ben Soussan E et al.
82 %29 %36Acta Gastroenterol Belg 2005Moreno et al.
66 %41.9 %44Endoscopy 2004Delvaux et al.
37.5 %68 %56Am J Gastroenterol 2005Neu et al.
Therapeutic Decision based
on VCE
Diagnostic Yield of VCE
N patients
P2 P1 P0
Clinical Relevance of P2 lesions34 Patients with intestinal lesions detected at the initial VCE
15 P2 lesions 14 P1 lesions 5 P0 lesions
10 treated 4 treated1 patient with an other source of bleeding
diagnosed afterwards
9 patients with an other source of
bleeding diagnosed afterwards
Saurin et al. Endoscopy 2005; 37: 318-323
P = 0.02
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 20032 Eliakim et al. Eur. J. Gastroenterol. Hepatol. 20023 Rodriguez-Tellez M et al. Endoscopy 2002
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 20052 Boureille A et al. Gastrointest Endosc 20053 Colombel JF et al. Endoscopy 2005
Role of VCE in management of Crohn’s disease
• Need for biopsies– Association of VCE with Push-and-
Pull 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
1Krauss NG et al. Gastrointest Endosc 20052de Franchis R et al. Gastrointest Endosc 20053 Gay et al. Gastrointest Endosc 20024Dubencenco E et al. Gastrointest Endosc 20055Apostolopoulos P. et al., Endocopy 2004
• 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
Some further indications…• Malabsorption Syndromes…• Diffuse intestinal diseases…
Amyloidosis
Eosinophilic gastro-enteritisExsudative enteropathy
Whipple
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
GISTADKT-cellAdenomaLipomaCarcinoidMetastasesHaemangiomaMiscellaneous
48 patients with an Intestinal Tumour
VCE in Familial Polyposis Syndromes
SCHULMAN K et al Gastrointest Endosc. 2003VARADARAJULU S et al. Gastrointest. Endosc. 2004
Surveillance of hereditary polyposis syndromes– FAP : Familial adenomatous Polyposis – PJS : Peutz-Jeghers Syndrome– FJP : Juvenile Familial Polyposis
Surveillance of HNPCC (Lynch)- Not validated- Schulman, Gastrointest. Endosc. 2005
CASPARI R. Endoscopy 200420 patients FJP = 4
FAP = 16In 8 patients VCE showed 448 polyps of 1 to 3 mmIn 4 patients MRI 24 polyps > 5 mm
Tolerance of SB Pill Cam
• Interference with pace-makers and other stimulators: no longer a contraindication1
• Capsule retention– Mainly related to transit issues
• Delayed gastric emptying• Motility disorders• Zencker’s diverticulum• Anatomical stenoses
1LEIGHTON et al. Gastroenterology 2003
Frequency of Capsule Retention• Frequency of capsule retention
– Obscure digestive bleeding 1089 pts 1.5 %• Barkin and Friedman, Am. J. Gastroenterol. 2002• Pennazio et al. Gastroenterology 2004• Sears et al. Gastrointest. Endosc. 2004
– Crohn’s disease 250 pts 1.4 - 5 %• 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. 1696 pts 1.8 %• Z. Gastroenterol 2004
• Surgical indication for capsule retention– Barkin JS, Friedman S 937 pts 0.8 %
• 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 diseaseNo indicator with significant PPV / NPV
The AGILE Patency Capsule
Timer Plugs
Lactose Body w/ Barium
RFID tag
Exposed windows
Parylene Coating
Patency CapsuleDisintegration and Terminology Post Excretion
Intact Body
Body is intact and hard. Plugs
have eroded.
Intact Capsule
Body and Plugsare virtually intact
Disintegrating Body
Body is losing its original dimensions and becomes soft
Empty Shell and Tag
Capsule contents have disintegrated
Body
Plug
Plug
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 lesionTransit time caecum ≥ 0.75 PPE Anal route
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 50 100 150 200 250 300 350 400
Time to the lesion (min.)
Tim
e In
dex
Lesi
on/C
aecu
m -
min
)
Oral route
Anal route
PPV = 94.7 %NPV = 96.7 %
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…
PILLCAM (11X33) Capsule container(11X33)
Flexible plastic bondFRITSHER A Gastrointest Endosc 2005
• 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 ?
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