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Capsule endoscopy_ A new dimension of endoscopy Final.pptx

  1. Capsule Endoscopy: A Revolution in the Endoscopic Field Dr. Md. Yasir Arafat MRCP, MD, ESEGH Sheikh Russel National Gastroliver Institute and Hospital, Dhaka
  2. 1971 Sonde type enteroscopy 1957 Fiberoptic endoscopy BY Mr. Basil 1969 Dr. William and Dr. Hiromi- fiberoptic colonoscope 2001 Double balloon enteroscopy 2001 Capsule endoscopy- opened the black box Evolution of fiberoptic endoscopy system
  3. Capsule endoscopy: A revolution in the endoscopic field
  4. Capsule endoscopy: A revolution in endoscopic field Allows physicians to visualize the entire gastrointestinal tract from the esophagus to the colon. No sedation required Eliminates discomfort
  5. Basic aspect CE
  6. Song, Hyun & Shim, Ki-Nam. (2016). Current status and future perspectives of capsule endoscopy. Intestinal Research. 14. 21. 10.5217/ir.2016.14.1.21. Technical aspect
  7. Travel route of capsule endoscopy
  8. Capsule Endoscopy system
  10. Preparation for small bowel capsule endoscopy ● SB-VCE- fasting or consumption of clear liquids for 10 to 12 hours is commonly recommended ○ ESGE recommends that prior to SBCE patients ingest a purgative (2 L of polyethylene glycol [PEG]) for better visualization. ● A diet of clear liquids is allowed after 2 hours from capsule ingestion and a light meal after 4 hours ● Typical reading times vary between 30 and 120 minutes for SB- VCE
  11. ● Bowel preparations for CCE-2 are intensive ○ A clear liquid diet is recommended on the day before the procedure, and a split-dose 4-L polyethylene glycol preparation is used ○ After the capsule enters the small bowel, an alert (Alert 1) prompts all patients to ingest a “booster” of 6 ounces of sodium sulfate/potassium sulfate/magnesium sulfate (Braintree Laboratories, Braintree, Mass, USA) diluted to 16 ounces with water, followed by 1 L of water American Society for Gastrointestinal Endoscopy (ASGE)
  12. ● ASGE guidelines state that readers of VCE should have either undergone formal VCE training during fellowship or have completed a formal GI- or surgical society-endorsed training course with proctoring of the first 10 capsule readings American Society for Gastrointestinal Endoscopy (ASGE)
  13. Indication of Small Bowel-VCE ● Evaluation of both overt and occult small- bowel bleeding VCE in hereditary haemorrhagic telangiectsia VCE during active bleeding at terminal ileum
  14. ● Suspected, known, or relapsed CD when ileocolonosco py and imaging studies were negative Indication of Small Bowel-VCE
  15. ● Surveillan ce of polyposis syndrome s Indication of Small Bowel-VCE (García-Márquez, J. & Damas, M. & Caballero Mateos, Antonio. (2020). Video capsule endoscopy in the diagnosis of Peutz-Jeghers syndrome. Revista de Gastroenterología de México (English Edition). 85. 10.1016/j.rgmxen.2019.10.003.)
  16. ● Suspected small intestine tumours Indication of Small Bowel-VCE
  17. ● Suspected or refractory malabsorptive syndromes (eg- celiac disease, lymphangiectasia ) Indication of Small Bowel-VCE  Villous atrophy in celiac disease- Subtotal to total atrophy Marsh class iii-iv (a)  Marsh class ii (b)  normal (c &d)  Scalloping, fissure and mosaic mucosal pattern in VCE (a) and enteroscopy (b)
  18. Lymphangiectasia with mucosal oedema and a whitish patch of villi Indication of Small Bowel-VCE
  19. Meta-analysis on SB-VCE Vs DBE ● Overall yield was not statistically different SB-VCE (60%, n = 397) and DBE (57%, n =360) Clinical Gastroenterology and Hepatology Volume 6 Issue 6 Pages 671-676 (June 2008) DOI: 10.1016/j.cgh.2008.01.005
  20. VCE Vs CT ● VCE- better for detecting ulcers, enteritis, and angiodysplasia ● CTE- more sensitive in detecting tumors and Meckel diverticula American Society for Gastrointestinal Endoscopy (ASGE)
  21. Colon VCE PillCam COLON 2 and PillCam Crohn’s- FDA approved ● Detection of colon polyps in patients with evidence of GI bleeding of lower GI origin- In a meta-analysis of 7 studies (n = 1292) that used the CCE-2 system, the sensitivity for polyps >6 mm was 86.0% and specificity was 88.1% ● PillCam Crohn’s has been cleared by the FDA for visualization of the small bowel and colonic mucosa American Society for Gastrointestinal Endoscopy (ASGE)
  22. Upper GI VCE The PillCam UGI capsule (Medtronic, Minneapolis, Minn, USA) ● For esophagus and stomach ○ patients who either refuse or are otherwise unable to undergo OGD ■ suspected Barrett’s esophagus (BE) ■ reflux esophagitis ■ esophageal varices ● Battery life is only 90 minutes American Society for Gastrointestinal Endoscopy (ASGE)
  23. PillCam Patency capsule ● Patency capsule has similar dimensions (11.4 mm 26.4 mm) ● At 30 hours, time- controlled plugs at the ends of a retained capsule erode, allowing intestinal fluids to dissolve the capsule body Patency capsule: a. Intact b. Without tag c & d. After degradation
  24. Patency capsule indicator blue light and presence of tag in X-ray PillCam Patency capsule
  25. a) Intact patency capsule 24 hours after ingestion b) Patency capsule tag presence after 50 hours. VCE therefore contraindicated c) Presence of tight stricture in CT d) Impassably tight jejunal stenosis with ulcer at enteroscopy PillCam Patency capsule
  26. ● Presence of patency capsule tag after 65 hours (a) ● CT shows a stricture at ileum (b) ● After surgery, small bowel adenocarcinoma with stricture with remnant of patency capsule is found (c) PillCam Patency capsule
  27. Contraindication of SB-VCE ● Known or suspected intestinal obstruction, strictures, or fistulas ● ? Presence of pacemakers, defibrillators(ICD), or left ventricular assist devices(VAD) ○ ESGE recommends that patients with pacemakers, ICD, VAD, can safely undergo SBCE without special precautions Stenosis and two retained Video capsules Pacemaker and ICD
  28. ● ?MRI is anticipated within 1 week of capsule ingestion (Acc. Manufacturer instruction) ● Swallowing disorders to avoid aspiration- Endoscopic placement is an option ● Pregnancy- adequate safety data is not available Contraindication
  29. Adverse events ● Capsule retention (1.4%) ○ CD (35.3%) ○ ESGE recommends observation in cases of asymptomatic capsule retention ● Intestinal perforation- Exceedingly rare (only two case reports to date) ● Capsule aspiration (0.1%) American Society for Gastrointestinal Endoscopy (ASGE)
  30. Disadvantage of VCE Promising solution Incomplete small bowel examination Low-quality image Chromoendoscopy and 3D reconstruction Uncontrolled air insufflation Controlled CO2 insufflation Retention or delayed transition External real-time image viewer Limited battery life Frame rate modulation and Video compression
  31. Other disadvantage of VCE ● Impossibility of maneuver ● Therapeutic or biopsy capability ● Delayed time of the interpretation
  32. ● (A) A capsule that emits magnetic force ● (B) A capsule with legs for mucosal ambulation ● (C) A capsule that involves use of a paddling stroke ● (D) A capsule with four propellers Promising solution
  33. Summary ● VCE allows a minimally invasive approach ● VCE- a first-line approach in the evaluation of small- bowel bleeding ● It is an emerging modality in the evaluation of disease severity of CD ● CCE is an emerging screening modality for the detection of colorectal neoplasia for those unable or unwilling to consider colonoscopy for screening