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