Colon capsule endoscopy:What we know and what we would like to know

Colonoscopy is usually perceived as an invasive and potentially painful procedure, being also affected by a small, but definite, risk of major complications (cardiopulmonary complications, perforation, hemorrhage) and even mortality. To improve both acceptability and safety, PillCam Colon Capsule Endoscopy (CCE) (Given Imaging Ltd, Yoqneam, Israel) has been developed. CCE represents a non-invasive technique that is able to explore the colon without sedation and air insufflation. The Second Generation of Colon Capsule Endoscopy (PillCam Colon 2) (CCE-2) was proven to be an accurate tool to detect colonic neoplastic lesions when used in average risk individuals. To date, the evidence supports the use of CCE-2 in case of colonoscopy failure, in patients unwilling to perform colonoscopy and when colonoscopy is contraindicated. Other potential applications, such as colorectal cancer screening or diagnostic surveillance of inflammatory bowel disease need to be clarified. In this paper, the current “state of the art”, potential application of CCE and future needs are evaluated.

BRIEF ARTICLE New reduced volume preparation regimen in colon capsule endoscopy

AIM:To evaluate the effectiveness of our proposed bowel preparation method for colon capsule endoscopy.METHODS:A pilot,multicenter,randomized controlled trial compared our proposed "reduced volume method"(group A) with the "conventional volume method"(group B) preparation regimens.Group A did not drink polyethylene glycol electrolyte lavage solution(PEGELS) the day before the capsule procedure,while group B drank 2 L.During the procedure day,groups A and B drank 2 L and 1 L of PEG-ELS,respectively,and swallowed the colon capsule(PillCam COLON capsule).Two hours later the first booster of 100 g magnesium citrate mixed with 900 mL water was administered to both groups,and the second booster was administered six hours post capsule ingestion as long as the capsule had not been excreted by that time.Capsule videos were reviewed for grading of cleansing level,RESULTS:Sixty-four subjects were enrolled,with results from 60 analyzed.Groups A and B included 31 and 29 subjects,respectively.Twenty-nine(94%) subjects in group A and 25(86%) subjects in group B had adequate bowel preparation(ns).Twenty-two(71%) of the 31 subjects in group A excreted the capsule within its battery life compared to 16(55%) of the 29 subjects in group B(ns).Of the remaining 22 subjects whose capsules were not excreted within the battery life,all of the capsules reached the left side colon before they stopped functioning.A single adverse event was reported in one subject who had mild symptoms of nausea and vomiting one hour after starting to drink PEG-ELS,due to ingesting the PEG-ELS faster than recommended.CONCLUSION:Our proposed reduced volume bowel preparation method for colon capsule without PEG-ELS during the days before the procedure was as effective as the conventional volume method.

Colon capsule endoscopy: Current status and future directions

Colon capsule endoscopy(CCE; Pill Cam Colon; Given Imaging; Yoqneam, Israel) is a minimally invasive wireless technique for the visualization of the colon. With the recent introduction of the second generation colon capsule the diagnostic accuracy of CCE for polyp detection has significantly improved and preliminary data suggest it may be useful to monitor mucosal inflammation in patients with inflammatory bowel disease. Limitations include the inability to take biopsies and the procedural costs. However, given the potentially higher acceptance within an average risk colorectal cancer(CRC) screening population, its usefulness as a screening tool with regard to CRC prevention should be further evaluated.

Follow-up outcomes in patients with negative initial colon capsule endoscopy findings

BACKGROUND Colon capsule endoscopy(CCE),which became clinically applicable in 2006,is a simple and noninvasive procedure to evaluate colonic diseases;the accuracy of second-generation CCE,introduced in 2009,has dramatically improved.Currently,CCE is used as an alternative method for colorectal cancer screening,as well as for evaluating the mucosal lesions of inflammatory bowel disease,in cases where performing colonoscopy(CS)is difficult.However,the outcomes of CCE are uncertain.AIM To investigate the outcomes of Japanese patients with negative findings(no polyps or colorectal cancer)on initial CCE.METHODS This retrospective,single-center study was conducted at the Endoscopic Center at Aishinkai Nakae Hospital.This study included patients who underwent continuous CCE between November 2013 and August 2019,that exhibited no evidence of polyps or colorectal cancer at the initial CCE,and could be followed up using either the fecal immunochemical test(FIT),CS,or CCE.The observational period,follow-up method,presence or absence of polyps and colorectal cancer,pathological diagnosis,and number of colorectal cancer deaths were evaluated.RESULTS Thirty-one patients(mean age,60.4±15.6 years;range,28–84 years;14 men and 17 women)were enrolled in this study.The reasons for performing the first CCE were screening in 12,a positive FIT in six,lower abdominal pain in nine,diarrhea in two,and anemia in two patients.The mean total water volume at the time of examination was 3460±602 mL(2250–4800 mL),and a total CS was performed in 28 patients(90%).The degree of cleanliness was excellent in 15 patients and good in 16,and no poor cases were observed.No adverse events,such as retention or capsule aspiration,were observed in any of the patients.The mean follow-up period was 3.1±1.5 years(range,0.3–5.5 years).Follow-up included FIT in nine,CS in 20,and CCE in four patients(including duplicate patients).The FIT was positive in two patients,while CS revealed five polyp lesions(three in the ascending colon,one in the transverse colon,and one in the descending colon),with sizes ranging between 2 mm and 8 mm.Histopathological findings revealed a hyperplastic polyp in one patient,and adenoma with low grade dysplasia in four patients;colorectal cancers were not recognized.In the follow-up example by CCE,polyps and colorectal cancer could not be recognized.During the follow-up period,there were no deaths due to colorectal cancer in any of the patients.CONCLUSION We determined the outcomes in patients with negative initial CCE findings.

The Use of Castor Oil for Bowel Preparation for Colon Capsule Endoscopy

Colon capsule endoscopy was approved for reimbursement under the national health insurance system of Japan in 2014. At our hospital, specialized mainly in renal, hepatic, and diabetic diseases, we have been performing colon capsule endoscopy since December 2014. Dialysis patients are potentially susceptible to bleeding because of the fragile intestine, impaired platelet function, or oral administration of nonsteroidalanti inflammatory drugs (NSAIDs) or anticoagulants. For this reason, detailed examination by capsule endoscopy appears to be useful. However, the capsule excretion rate after recommended bowel preparation reportedly ranges from 70% to 90%, and administration of boosters is also necessary. For dialysis patients, liquid loading is a problem. In this study, we evaluated the efficacy of bowel preparation with castor oil for improving the capsule excretion rate. In all 20 patients (including four dialysis patients), both capsule transit time and duration of capsule endoscopy were shortened. The results are presented and briefly discussed in this report.

Castor oil as booster for colon capsule endoscopy preparation reduction: A prospective pilot study and patient questionnaire

BACKGROUND Preparation for colon capsule endoscopy(CCE)requires a large liquid laxative volume for capsule excretion,which compromises the procedure's tolerability.AIM To assess the safety and utility of castor oil-boosted bowel preparation.METHODS This prospective cohort study including 20 patients(age range,16-80 years;six men and 14 women)suspected of having colorectal disease was conducted at Kindai University Hospital from September 2017 to August 2019.All patients underwent CCE because of the following inclusion criteria:previous incomplete colonoscopy in other facility(n=20),history of abdominal surgery(n=7),or organ abnormalities such as multiple diverticulum(n=4)and adhesion after surgery(n=6).The exclusion criteria were as follows:Dysphagia,history of allergic reactions to the drugs used in this study(magnesium citrate,polyethylene glycol,metoclopramide,and castor oil),possibility of pregnancy,possibility of bowel obstruction or stenosis based on symptoms,or scheduled magnetic resonance imaging within 2 wk after CCE.The primary outcome was the capsule excretion rate within the battery life,as evaluated by the total large bowel observation rate,large bowel transit time,and bowel creasing level using a fivegrade scale in different colorectal segments.The secondary outcomes were complications,colorectal lesion detection rates,and patients’tolerability.RESULTS The castor oil-based regimen was implemented in 17 patients.Three patients cancelled CCE because they could tolerate castor oil,but not liquid laxatives.The capsule excretion rate within the battery life was 88%(15/17).The mean large bowel transit time was 236 min.Approximately 70%of patients had satisfactory colon cleansing levels.CCE detected colon polyps(14/17,82%)and colonic diverticulum(4/12,33%).The sensitivity,specificity,and diagnostic accuracy rates for detecting colorectal polyps(size≥6 mm)were 76.9%,75.0%,and 76.4%,respectively.The sensitivity,specificity,and diagnostic accuracy rates for detection of diverticulum were 100%each.Twelve patients(71%)rated CCE as more than“good”,confirming the new regimen’s tolerability.No serious adverse events occurred during this study.CONCLUSION The castor oil-based regimen could reduce bowel preparation dose and improve CCE tolerability.

Addition of castor oil as a booster in colon capsule regimens significantly improves completion rates and polyp detection

BACKGROUND Incomplete excretion rates are problematic for colon capsule endoscopy(CCE).Widely available booster regimens are suboptimal.Recently published data on one day preparation CCE protocol using castor oil appeared effective.AIM To assess the impact of adding castor oil to a standard split-dose(2-d)preparation in an unselected Western patient cohort.METHODS All patients aged 18 or more referred to our unit for a CCE over a 5-mo period were prospectively recruited.Controls were retrospectively identified from our CCE database.All patients received split bowel preparation with Moviprep■[polyethylene glycol(PEG)-3350,sodium sulphate,sodium chloride,potassium chloride,sodium ascorbate and ascorbic acid for oral solution;Norgine B.V,United States],a PEG-based solution used predominantly in our colonoscopy practice.Control booster regimen included Moviprep■with 750 mL of water(booster 1)on reaching the small bowel.A further dose of Moviprep■with 250 mL of water was given 3 h later and a bisacodyl suppository(Dulcolax■)10 mg after 8 h,if the capsule was not excreted.In addition to our standard booster regimen,cases received an additional 15 mL of castor oil given at the time of booster 1.A nested case control design with 2:1 ratio(control:case)was employed.Basic demographics,completion rates,image quality,colonic transit time,diagnostic yield and polyp detection were compared between groups,using a student t or chi-square tests as appropriate.RESULTS One hundred and eighty-six CCEs[mean age 60 years(18-97),56%females,n=104],including 62 cases have been analysed.Indication breakdown included 96 polyp surveillance(51.6%),42 lower gastrointestinal symptoms(22.6%),28 due to incomplete colonoscopy(15%),18 anaemia(9.7%)and 2 inflammatory bowel disease surveillance(1.1%).Overall,CCE completion was 77%(144/186),image quality was adequate/diagnostic in 91%(170/186),mean colonic transit time was 3.5 h(0.25-13),and the polyp detection rate was 57%(106/186).Completion rates were significantly higher with castor oil,87%cases(54/62)vs 73%controls(90/124),P=0.01.The number needed to treat with castor oil to result in an additional complete CCE study was 7,absolute risk reduction=14.52%,95%confidence interval(CI):3.06-25.97.This effect of castor oil on excretion rates was more significant in the over 60 s,P<0.03,and in females,P<0.025.Similarly,polyp detection rates were higher in cases 82%(51/62)vs controls 44%(55/124),P=0.0001,odds ratio 5.8,95%CI:2.77-12.21.Colonic transit times were similar,3.2 h and 3.8 h,respectively.Image quality was similar,reported as adequate/diagnostic in 90%(56/62)vs 92%(114/124).CONCLUSION In our capsule endoscopy centre,castor oil addition as a CCE booster significantly improved completion rates and polyp detection in an unselected Western cohort.

PillCamColon2 after incomplete colonoscopy-A prospective multicenter study

AIM To evaluate the ability of PillCamColon2 to visualize colonic segments missed by incomplete optical colonoscopy(OC) and to assess the diagnostic yield.METHODS This prospective multicentre study included 81 patients from nine centres who underwent second-generation colon capsule endoscopy(CCE) following incomplete OC performed by an experienced gastroenterologist(> 1000 colonoscopies). Patients with stenosis were excluded. According to patient preferences, CCE was performed the following day(protocol A) after staying on clear liquids and 0.75 L Moviprep in the morning or within 30 d after new split-dose Moviprep(protocol B). Boosts consisted of 0.75 L and 0.25 L Moviprep, and phospho-soda was given as a rescue if the capsule was not excreted after seven hours.RESULTS Seventy-four patients were analysed(51% of them in group A; 49% in group B). Bowel cleansing was adequate in 67% of cases, and CCE could visualize colonic segments missed by incomplete colonoscopy in 90% of patients under protocol A and 97% of patients under protocol B(P = 0.35, n.s.). Significant polyps including adenocarcinoma were detected in 24% of cases. Detection rates for all polyps and significant polyps per patient were similar in both protocols. Polyps were found predominantly in the right colon(86%) in segments that were not reached by OC. Extracolonic findings-such as reflux esophagitis, suspected Barrett esophagus, upper GI-bleeding, gastric polyps, gastric erosions and angiectasia-were detected in eight patients. Pill Cam Colon2 capsule was retained in the ileum of one patient(1.4%) without symptoms and removed during an uneventful resection for unknown Crohn's disease that was diagnosed as the cause of anemia, which was the indication for colonoscopy. CCE was well tolerated. One patient suffered from selflimiting vomiting after consuming the phospho-soda.CONCLUSION Second-generation CCE using a low-volume preparation is useful after incomplete OC, and it allows for the detection of additional relevant findings, but cleansing efficiency could be improved.

Capsule endoscopy in patients refusing conventional endoscopy

Capsule endoscopy is nowadays the diagnostic technique of choice in the study of small bowel pathologies,allowing the non-invasive study of the entire mucosa.This has led,together with new technical advances,to the creation of two new models(PillCam ESO and PillCam Colon)for the study of esophageal and colonic diseases.These two new capsules offer an interesting alternative to conventional endoscopy in the study of the upper and lower digestive tracts,because traditional endoscopy is often unpleasant and uncomfortable for the patient,can be painful,often requires moderate or deep sedation and is not without complications(hemorrhage,perforation,etc.).PillCam Colon is particularly important for its usefulness in the diagnosis of colonic polyps,and is a potentially useful tool in cases of incomplete colonoscopy or in colorectal cancer screening,even more when most patients are reluctant to undergo screening programs due to the said disadvantages of conventional colonoscopy.This article discusses the advantages of capsule endoscopy over conventional endoscopy,its current application possibilities and indications in routine clinical practice.In the various sections of the work,we assess the application of endoscopic capsule in different sections of the digestive tract(esophagus,stomach,and colon)and finally the potential role of panendoscopy with PillCam Colon.

Wireless capsule endoscopy: Perspectives beyond gastrointestinal bleeding

Wireless capsule endoscopy(CE) is a technology developed for the endoscopic exploration of the small bowel. The first capsule model was approved by the Food and Drug Administration in 2001, and its first and essential indication was occult gastrointestinal(GI) bleeding. Over subsequent years, this technology has been refined to provide superior resolution, increased battery life, and capabilities to view different parts of the GI tract. Indeed, cases for which CE proved useful have increased significantly over the last few years, with new indications for the small bowel and technical improvements that have expanded its use to other parts of the GI tract, including the esophagus and colon. The main challenges in the development of CE are new devices with the ability to provide therapy, air inflation for a better vision of the small bowel, biopsy sampling systems attached to the capsule and the possibility to guide and move the capsule with an external motion control. In this article we review the current and new indications of CE, and the evolving technological changes shaping this technology, which has a promising potential in the coming future of gastroenterology.