Capsule Endoscopy

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Capsule Endoscopy

• Manish D. Shah, MD
• University Hospitals Case Medical Center/
• Louis Stokes Cleveland VA Medical Center
• Senior Talk
• December 19 21, 2007

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Learning Objectives

• How does capsule endoscopy work?
• How does a patient need to be prepped?
• What are the indications, contraindications, and
  limitations of capsule endoscopy?
• What are the potential complications of capsule
  endoscopy?

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History of Endoscopy

• The first real endoscope that was developed was
  made by Phillip Bozzini in 1805 to examine the
  urethra, the bladder and vagina.

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Bozzinis Lichtleiter
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History of Endoscopy

• Adolf Kussmaul in 1868 used a straight rigid
  metal tube over a flexible obturator to perform
  the first gastroscopy.

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Kussmauls Gastroscope
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History of Endoscopy

• Building on the work of others, Rudolph Schindler
  constructed the first practical gastroscope in
  1932.

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Wolf-Schidler Flexible Gastroscope
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History of Endoscopy

• In 1957 Basil Hirschowitz developed his prototype
  fiberscope.

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Limitation of Fiberoptic Endoscopy
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Double Balloon (Push-and-Pull) Endoscopy

• Fiberoptic method to visual the entire small
  bowel
• Indication
• Obscure GI tract bleeding
• Iron deficiency anemia with normal colonoscopy
  EGD
• Visualization and therapeutic intervention on
  abnormalities in the small intestine

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Double Balloon (Push-and-Pull) Endoscopy

• Technique
• Uses a balloon at the end of a special endoscope
  and an overtube, which is also fitted with a
  balloon.
• The endoscope and overtube is inserted and passed
  in a conventional fashion into the small bowel.
• Following this, the endoscope is advanced a small
  distance in front of the overtube and the balloon
  at the end is inflated.
• The endoscope is then pulled back, which pulls
  the small bowel back to the overtube.
• The overtube balloon is inflated and the
  endoscope balloon is deflated.
• The process is repeated with advancement of the
  endoscope.

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Double Balloon (Push-and-Pull) Endoscopy

• Advantages over Capsule Endoscopy
• Complete visualization of the entire small bowel
  to the terminal ileum
• Can do therapeutic interventions
• Allows for sampling/biopsying of small bowel
  mucosa
• Allows for resection of polyps
• Placement of stents or dilation of small bowel
  strictures

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Double Balloon (Push-and-Pull) Endoscopy

• Disadvantages
• Technically difficult procedure
• Very time consuming (Procedure can take gt 3
  hours)
• Patient may need to be admitted to the hospital
• Higher risk of small bowel perforation
• Case reports of pancreatitis and intestinal
  necrosis
• Reported incidents of aspiration and pneumonia

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Capsule Endoscopy

• Capsule endoscopy was first used in humans in
  1999.
• First publication on capsule endoscopy was
  published in Nature in 2000
• Iddan G, Meron G, Glukhovsky A, Swain P.
  Wireless capsule Endoscopy. Nature. 2000
  405417.

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Capsule Endoscopy

• Two major companies have capsule endoscopy
  products.
• Given Imaging has the PillCam
• Olympus has the EndoCapsule

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Types of Endoscopic Capsules
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Prep for Capsule Endoscopy

• Patient should be NPO for 12 hours prior to
  procedure.
• Oral iron should be stopped 3 days before the
  study.
• Colonic bowel prep may improve the quality of
  images in the ileum, which can appear dark.
  However no regimen has been proven better than
  any other.

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How does Capsule Endoscopy Work?

• Capsule is initially stored in a case containing
  a magnet that inhibits capsule activation. Once
  it taken out of the case, the LEDs start to flash
  and the capsule start to transmit.
• Eight aerial leads that are attached around the
  patients abdomen collect data.
• Capsule ingested as any other capsule.
• Patient can drink clears immediately, but no
  solid food for 3 hours.
• Attached to the leads is the recorder and the
  patient should report back if it stops recording
  for any reason.
• Belt and aerial should be worn for 8 hours after
  swallowing or until the recorder stops recording.
• Recorder and aerials are returned, but the
  capsule is disposable!
• Images are downloaded and processed prior to
  interpretation.

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Placement of Aerial Leads
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Given Imaging Rapid Viewing Screen
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Images from Capsules
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Indications for Capsule Endoscopy

• Absolute Indication
• Recurrent or continued GI bleeding with negative
  EGD, colonoscopy, and push enteroscopy
• Strong Indication
• Recurrent or continued GI bleeding with negative
  EGD and colonoscopy, especially if exams have
  been repeated by experienced endoscopist.
• Persistent iron deficiency anemia w/ negative EGD
  and Colonoscopy

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Indications for Capsule Endoscopy

• Emerging Indications
• Symptoms/Inflammatory markers suggesting Crohns
  disease with negative imaging
• Investigation of unresponsive Celiac disease
• Whipples Disease
• Graft Vs. Host disease
• HIV
• Intestinal parasitosis
• Peutz-Jeghers polyposis
• Small-intestinal abnormalities on SBFT or CT
• Assessment of NSAID small intestinal damage

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Contraindications to Capsule Endoscopy

• Presence of known intestinal strictures,
  fistulas, or obstruction
• Small children
• Patients with swallowing disorders
• There has been some concern that there is a risk
  of interfering with pacemakers due to the
  proximity of the sensor arrays placed on the
  patients chests, but no significant trials have
  confirmed this fear.

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Limitations of Capsule Endoscopy

• Slow Gastric/Intestinal Motility.
• Poorer quality of images as compared to
  Fiberoptic scopes
• The position of the capsule can not be accurately
  controlled
• Potentially obstructed views
• Morbidly obese patients
• Interpretation of results are very observer
  dependent
• Findings may be of unknown significance or
  relevance.
• Inability to biopsy or treat any pathology seen.

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Complications of Capsule Endoscopy

• Impaction in strictures or diverticula are the
  main complication

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Case Study 1

• HPI 72-year old woman with unexplained iron
  deficiency anemia. Hgb 10, MCV 82, RDW 13.
  Three cards for FOBT all positive. She has
  Gauchers Disease with resulting platelet
  dysfunction.
• Pt had a normal EGD and colonoscopy 4 months
  earlier. CT Scan was done and was negative.
• FHx celiac disease

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Case Study 1

• Capsule Endoscopy Pictures

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Case Study 1

• Capsule endoscopy shows multiple submucosal
  masses. Some are ulcerated and bleeding. These
  are located in the mid-small bowel. A
  presumptive diagnosis of multicentric carcinoid
  is made.
• The patient undergoes surgery guided by
  intraoperative endoscopy. Multiple carcinoid
  tumors are discovered and a mid-small bowel
  resection is performed.

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Case Study 2

• HPI Pt is a 49 yo F with progressive iron
  deficient anemia, post-prandial abdominal pain,
  and diarrhea. She has been maintained on iron
  supplementation to keep her Hgb at 10. She has
  had no rectal bleeding or change in her menses.
  Her weight has remained stable. No
  extraintestinal manifestations of IBD. No NSAID
  use.
• PE Unremarkable, guaiac negative stool.

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Case Study 2

• FHx Unremarkable.
• Labs Hgb/Hct 10/30. MCV 72. Normal chemistry
  profile. Iron saturation 5. ESR 35.
• Studies
• Colonoscopy with right-sided biopsies negative
  pathology
• EGD mild gastritis. Duodenal biopsies -
  normal, without villous atrophy
• SBFT/CT scan - negative

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Case Study 2

• Capsule Endoscopy Pictures

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Case Study 2

• Capsule revealed classic findings of celiac
  disease - villous atrophy, fissures, mosaic
  mucosal pattern in proximal small bowel.
• Celiac disease serologies obtained, post-capsule,
  revealed marked elevation of antitransglutaminase
  antibodies confirming the diagnosis.
• Anemia, pain, and diarrhea resolved on
  gluten-free diet.

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References

• Achord JL. The History of Gastrointestinal
  Endoscopy. In Ginsberg GG, Kochman ML, Norton
  I, Gostout CJ, Eds. Clinical Gastrointestinal
  Endoscopy. Elsevier Saunders 2005 3-11.
• Baichi MM, Arifuddin RM, Mantry PS. What we
  learned from 5 cases of permanent capsule
  retention. Gastrointestinal Endoscopy. 2006 64
  (2) 283-287.
• Fortun, PJ, Swain, CP. Capsule Endoscopy. In
  Weinstein WM, Hawkey CJ, Bosch J, Eds. Clinical
  Gastroenterology and Hepatology. Elsevier Mosby
  2005 915-920.
• Haubrich WS, Edmonson JM. History of Endoscopy.
  In Sivak, MV, Ed. Gastroenterologic Endoscopy.
  W.B. Saunders 2000 2-15.

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References

• Iddan G, Meron G, Glukhovsky A, Swain P.
  Wireless capsule Endoscopy. Nature. 2000
  405417.
• Mazzarolo S, Brady P. Small Bowel Capsule
  Endoscopy A Systemic Review. Southern Medical
  Association. 2007 100 (3) 274-280.
• Pennazio, M. Enteroscopy and capsule endoscopy.
  Endoscopy. 2006 38 (11) 1079-1086.
• Rey JF, Ladas S, Alhassani A, Kuznetsov K, ESGE
  Guidelines Committee. European Society of
  Gastrointestinal Endoscopy (ESGE) Video capsule
  endoscopy Update to guidelines (May 2006).
  Endoscopy. 2006 38 (10) 1047-1053.

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References

• http//www.capsuleendoscopy.org
• http//www.olympusamerica.com/msg_section/endocaps
  ule/index.asp
• http//en.wikipedia.org/wiki/Double-Balloon_entero
  scopy

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Questions?
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