Capsule Endoscopy


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Capsule Endoscopy

  1. 1. Capsule Endoscopy Manish D. Shah, MD University Hospitals Case Medical Center/ Louis Stokes Cleveland VA Medical Center Senior Talk December 19 & 21, 2007
  2. 2. Learning Objectives <ul><ul><li>How does capsule endoscopy work? </li></ul></ul><ul><ul><li>How does a patient need to be prepped? </li></ul></ul><ul><ul><li>What are the indications, contraindications, and limitations of capsule endoscopy? </li></ul></ul><ul><ul><li>What are the potential complications of capsule endoscopy? </li></ul></ul>
  3. 4. History of Endoscopy <ul><li>The first real endoscope that was developed was made by Phillip Bozzini in 1805 to examine the urethra, the bladder and vagina. </li></ul>
  4. 5. Bozzini’s Lichtleiter
  5. 6. History of Endoscopy <ul><li>Adolf Kussmaul in 1868 used a straight rigid metal tube over a flexible obturator to perform the first gastroscopy. </li></ul>
  6. 7. Kussmaul’s Gastroscope
  7. 8. History of Endoscopy <ul><li>Building on the work of others, Rudolph Schindler constructed the first practical gastroscope in 1932. </li></ul>
  8. 9. Wolf-Schidler Flexible Gastroscope
  9. 10. History of Endoscopy <ul><li>In 1957 Basil Hirschowitz developed his prototype fiberscope. </li></ul>
  10. 13. Limitation of Fiberoptic Endoscopy
  11. 14. Double Balloon (Push-and-Pull) Endoscopy <ul><ul><li>Fiberoptic method to visual the entire small bowel </li></ul></ul><ul><ul><li>Indication </li></ul></ul><ul><ul><ul><li>Obscure GI tract bleeding </li></ul></ul></ul><ul><ul><ul><li>Iron deficiency anemia with normal colonoscopy & EGD </li></ul></ul></ul><ul><ul><ul><li>Visualization and therapeutic intervention on abnormalities in the small intestine </li></ul></ul></ul>
  12. 15. Double Balloon (Push-and-Pull) Endoscopy <ul><ul><li>Technique </li></ul></ul><ul><ul><ul><li>Uses a balloon at the end of a special endoscope and an overtube, which is also fitted with a balloon. </li></ul></ul></ul><ul><ul><ul><li>The endoscope and overtube is inserted and passed in a conventional fashion into the small bowel. </li></ul></ul></ul><ul><ul><ul><li>Following this, the endoscope is advanced a small distance in front of the overtube and the balloon at the end is inflated. </li></ul></ul></ul><ul><ul><ul><li>The endoscope is then pulled back, which pulls the small bowel back to the overtube. </li></ul></ul></ul><ul><ul><ul><li>The overtube balloon is inflated and the endoscope balloon is deflated. </li></ul></ul></ul><ul><ul><ul><li>The process is repeated with advancement of the endoscope. </li></ul></ul></ul>
  13. 16. Double Balloon (Push-and-Pull) Endoscopy <ul><ul><li>Advantages over Capsule Endoscopy </li></ul></ul><ul><ul><ul><li>Complete visualization of the entire small bowel to the terminal ileum </li></ul></ul></ul><ul><ul><ul><li>Can do therapeutic interventions </li></ul></ul></ul><ul><ul><ul><li>Allows for sampling/biopsying of small bowel mucosa </li></ul></ul></ul><ul><ul><ul><li>Allows for resection of polyps </li></ul></ul></ul><ul><ul><ul><li>Placement of stents or dilation of small bowel strictures </li></ul></ul></ul>
  14. 17. Double Balloon (Push-and-Pull) Endoscopy <ul><ul><li>Disadvantages </li></ul></ul><ul><ul><ul><li>Technically difficult procedure </li></ul></ul></ul><ul><ul><ul><li>Very time consuming (Procedure can take > 3 hours) </li></ul></ul></ul><ul><ul><ul><li>Patient may need to be admitted to the hospital </li></ul></ul></ul><ul><ul><ul><li>Higher risk of small bowel perforation </li></ul></ul></ul><ul><ul><ul><li>Case reports of pancreatitis and intestinal necrosis </li></ul></ul></ul><ul><ul><ul><li>Reported incidents of aspiration and pneumonia </li></ul></ul></ul>
  15. 19. Capsule Endoscopy <ul><li>Capsule endoscopy was first used in humans in 1999. </li></ul><ul><li>First publication on capsule endoscopy was published in Nature in 2000: </li></ul><ul><ul><li>Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule Endoscopy. Nature . 2000; 405:417. </li></ul></ul>
  16. 20. Capsule Endoscopy <ul><li>Two major companies have capsule endoscopy products. </li></ul><ul><ul><li>Given Imaging has the PillCam </li></ul></ul><ul><ul><li>Olympus has the EndoCapsule </li></ul></ul>
  17. 21. Types of Endoscopic Capsules
  18. 23. Prep for Capsule Endoscopy <ul><ul><li>Patient should be NPO for 12 hours prior to procedure. </li></ul></ul><ul><ul><li>Oral iron should be stopped 3 days before the study. </li></ul></ul><ul><ul><li>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. </li></ul></ul>
  19. 24. How does Capsule Endoscopy Work? <ul><ul><li>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. </li></ul></ul><ul><ul><li>Eight aerial leads that are attached around the patient’s abdomen collect data. </li></ul></ul><ul><ul><li>Capsule ingested as any other capsule. </li></ul></ul><ul><ul><li>Patient can drink clears immediately, but no solid food for 3 hours. </li></ul></ul><ul><ul><li>Attached to the leads is the recorder and the patient should report back if it stops recording for any reason. </li></ul></ul><ul><ul><li>Belt and aerial should be worn for 8 hours after swallowing or until the recorder stops recording. </li></ul></ul><ul><ul><li>Recorder and aerials are returned, but the capsule is disposable! </li></ul></ul><ul><ul><li>Images are downloaded and processed prior to interpretation. </li></ul></ul>
  20. 25. Placement of Aerial Leads
  21. 26. Given Imaging Rapid Viewing Screen
  22. 27. Images from Capsules
  23. 28. Indications for Capsule Endoscopy <ul><ul><li>Absolute Indication </li></ul></ul><ul><ul><ul><li>Recurrent or continued GI bleeding with negative EGD, colonoscopy, and push enteroscopy </li></ul></ul></ul><ul><ul><li>Strong Indication </li></ul></ul><ul><ul><ul><li>Recurrent or continued GI bleeding with negative EGD and colonoscopy, especially if exams have been repeated by experienced endoscopist. </li></ul></ul></ul><ul><ul><ul><li>Persistent iron deficiency anemia w/ negative EGD and Colonoscopy </li></ul></ul></ul>
  24. 29. Indications for Capsule Endoscopy <ul><ul><li>Emerging Indications </li></ul></ul><ul><ul><ul><li>Symptoms/Inflammatory markers suggesting Crohn’s disease with negative imaging </li></ul></ul></ul><ul><ul><ul><li>Investigation of unresponsive Celiac disease </li></ul></ul></ul><ul><ul><ul><li>Whipple’s Disease </li></ul></ul></ul><ul><ul><ul><li>Graft Vs. Host disease </li></ul></ul></ul><ul><ul><ul><li>HIV </li></ul></ul></ul><ul><ul><ul><li>Intestinal parasitosis </li></ul></ul></ul><ul><ul><ul><li>Peutz-Jeghers polyposis </li></ul></ul></ul><ul><ul><ul><li>Small-intestinal abnormalities on SBFT or CT </li></ul></ul></ul><ul><ul><ul><li>Assessment of NSAID small intestinal damage </li></ul></ul></ul>
  25. 31. Contraindications to Capsule Endoscopy <ul><li>Presence of known intestinal strictures, fistulas, or obstruction </li></ul><ul><li>Small children </li></ul><ul><li>Patients with swallowing disorders </li></ul><ul><li>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. </li></ul>
  26. 32. Limitations of Capsule Endoscopy <ul><ul><li>Slow Gastric/Intestinal Motility. </li></ul></ul><ul><ul><li>Poorer quality of images as compared to Fiberoptic scopes </li></ul></ul><ul><ul><li>The position of the capsule can not be accurately controlled </li></ul></ul><ul><ul><li>Potentially obstructed views </li></ul></ul><ul><ul><li>Morbidly obese patients </li></ul></ul><ul><ul><li>Interpretation of results are very observer dependent </li></ul></ul><ul><ul><li>Findings may be of unknown significance or relevance. </li></ul></ul><ul><ul><li>Inability to biopsy or treat any pathology seen. </li></ul></ul>
  27. 34. Complications of Capsule Endoscopy <ul><li>Impaction in strictures or diverticula are the main complication </li></ul>
  28. 36. Case Study #1 <ul><li>HPI: 72-year old woman with unexplained iron deficiency anemia. Hgb 10, MCV 82, RDW 13. Three cards for FOBT all positive. She has Gaucher’s Disease with resulting platelet dysfunction. </li></ul><ul><li>Pt had a normal EGD and colonoscopy 4 months earlier. CT Scan was done and was negative. </li></ul><ul><li>FHx: celiac disease </li></ul>
  29. 37. Case Study #1 <ul><li>Capsule Endoscopy Pictures: </li></ul>
  30. 38. Case Study #1 <ul><li>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. </li></ul><ul><li>The patient undergoes surgery guided by intraoperative endoscopy. Multiple carcinoid tumors are discovered and a mid-small bowel resection is performed. </li></ul>
  31. 39. Case Study #2 <ul><li>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. </li></ul><ul><li>PE: Unremarkable, guaiac negative stool. </li></ul>
  32. 40. Case Study #2 <ul><li>FHx: Unremarkable. </li></ul><ul><li>Labs: Hgb/Hct 10/30. MCV 72. Normal chemistry profile. Iron saturation 5%. ESR 35. </li></ul><ul><li>Studies: </li></ul><ul><li>Colonoscopy with right-sided biopsies – negative pathology </li></ul><ul><li>EGD – mild gastritis. Duodenal biopsies - normal, without villous atrophy </li></ul><ul><li>SBFT/CT scan - negative </li></ul>
  33. 41. Case Study #2 <ul><li>Capsule Endoscopy Pictures: </li></ul>
  34. 42. Case Study #2 <ul><li>Capsule revealed classic findings of celiac disease - villous atrophy, fissures, mosaic mucosal pattern in proximal small bowel. </li></ul><ul><li>Celiac disease serologies obtained, post-capsule, revealed marked elevation of antitransglutaminase antibodies confirming the diagnosis. </li></ul><ul><li>Anemia, pain, and diarrhea resolved on gluten-free diet. </li></ul>
  35. 43. References <ul><li>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. </li></ul><ul><li>Baichi MM, Arifuddin RM, Mantry PS. What we learned from 5 cases of permanent capsule retention. Gastrointestinal Endoscopy. 2006; 64 (2): 283-287. </li></ul><ul><li>Fortun, PJ, Swain, CP. Capsule Endoscopy. In: Weinstein WM, Hawkey CJ, Bosch J, Eds. Clinical Gastroenterology and Hepatology. Elsevier Mosby; 2005: 915-920. </li></ul><ul><li>Haubrich WS, Edmonson JM. History of Endoscopy. In: Sivak, MV , Ed. Gastroenterologic Endoscopy. W.B. Saunders; 2000: 2-15. </li></ul>
  36. 44. References <ul><li>Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule Endoscopy. Nature . 2000; 405:417. </li></ul><ul><li>Mazzarolo S, Brady P. Small Bowel Capsule Endoscopy: A Systemic Review. Southern Medical Association. 2007; 100 (3): 274-280. </li></ul><ul><li>Pennazio, M. Enteroscopy and capsule endoscopy. Endoscopy. 2006; 38 (11): 1079-1086. </li></ul><ul><li>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. </li></ul>
  37. 45. References <ul><li> </li></ul><ul><li> </li></ul><ul><li> </li></ul>
  38. 46. Questions?
  39. 47. Happy Holidays Season’s Greetings