The diagnostic yield of capsule endoscopy depends on the quality of visualization of the small-bowel wall and complete passage through the small bowel. This study examined the effect of bowel preparation on the volume of intestinal content and on small-bowel transit.
Methods
Sixty-one consecutive patients (34 men, 27 women; mean age 56 years, range 17-88 years) were enrolled in the study. Although not randomized, 33 patients received a bowel preparation, and 28 had no preparation. Gastric emptying, small-bowel transit time, overall preparation assessment, and bowel-wall visualization were evaluated by 3 investigators who were unaware of whether the patient had undergone bowel preparation.
Results
Small-bowel transit time was significantly shorter in patients with bowel preparation (median 213 minutes: 95% CI[190, 267]) than in those without preparation (median 253 minutes: 95% CI[228, 307]) (p < 0.01). The capsule reached the cecum in 97% of patients in the bowel-preparation group, compared with 76% in the nonpreparation group (p = 0.02). Bowel preparation improved the quality of visualization significantly; this effect was more pronounced in the distal small bowel.
Conclusions
This study demonstrated that bowel preparation accelerates small-bowel capsule transit and leads to a higher rate of complete capsule endoscopy. Visualization of the small bowel was improved by bowel preparation. Bowel preparation before capsule endoscopy is recommended.
Section snippets
Patients and methods
Consecutive patients referred to two hospitals for CE over a period of 18 months were studied. In actual clinical practice, CE differs between the two hospitals with respect to bowel preparation. The study was nonrandomized: patients who had a bowel preparation (Group A) were recruited from the Department of Internal Medicine of the county hospital of St. Gallen, Switzerland; patients without bowel preparation (Group B) were recruited from the Department of Gastroenterology and Hepatology,
Results
A total of 65 consecutive patients underwent CE between March 2002 and September 2003. Four were excluded; 3 because of insufficient data from technical problems (2 data CDs not readable, 1 depleted battery). The third patient did not fast overnight, and massive amounts of residual food made assessment of the small-bowel impossible. The study, therefore, included 61 patients (34 men, 27 women; mean age 56 years, range 17-88 years). Without randomization, 33 patients received the bowel
Discussion
CE has been shown to be the most effective noninvasive method for evaluation of the small bowel, with a significantly higher diagnostic yield compared with push enteroscopy and conventional techniques.4, 5 It is safe, painless, well-tolerated, and has opened a new perspective in the diagnosis of recurrent GI bleeding of obscure origin, Crohn's disease, small-bowel tumors, and polyps.3
Despite its obvious advantages, CE has some limitations. Image quality is not as good as that of flexible
Acknowledgment
We thank Dr. Dieter Menne for statistical analysis of the data.
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There are more references available in the full text version of this article.
For proper evaluation of capsule endoscopy (CE), a complete examination is necessary.
We evaluated risk factors of an incomplete CE with focus on patient hospitalization.
We retrospectively evaluated 161 consecutive patients who underwent CE between 01.07.2013 and 13.03.2016. Main indications were active bleeding, iron deficiency anemia (IDA), inflammatory bowel disease (IBD), abdominal pain, and familial adenomatous polyposis (FAP).
We report the results of 103 in-patients and 56 out-patients. Eighty-two patients were male, average age was 58.9 years (range 18–90). Indications for CE were active bleeding (103 patients), IDA and IBD (16 patients), and FAP, abdominal pain and others (eight examinations each). All FAP patients were out-patients, but showed the longest small bowel transit time (SBTT) of 443.6 min (p = 0.0001). The shortest SBTT was found in out-patients without FAP (267.5 min, p < 0.05). In the in-patient group, nine endoscopies did not record the entire small bowel (8.7%) due to battery depletion, compared with only one incomplete examination in the out-patients (1.8%, p = 0.036). We found pathologic lesions in the last 30 min of the SBTT in 43 patients, and this indicates the necessity for complete examination. Thirteen of these 43 patients showed major lesions such as ulcers or angiodysplasia in this last region alone.
In-patients might require special treatment to ensure complete examination, since a considerable amount of pathologies can only be found in the ileum.
Controversy remains regarding the type and amount of precapsule bowel cleansing required for small-bowel video capsule endoscopy (VCE). This study aims to assess the efficacy and tolerance of 2 active preparations and a control group of clear fluids only.
Patients with clinical indications for VCE were randomized to (1) clear fluids only the evening before VCE, (2) 2 sachets of sodium picosulfate plus magnesium sulfate (P/MC) the evening before, or (3) 2 L of polyethylene glycol (PEG) the evening before. Diet instructions were the same for all 3 groups. Small-bowel cleansing was assessed in 3 ways: a 5-point ordinal scale (primary outcome), the percentage of time the small-bowel view was clear, and a validated computerized assessment of cleansing.
In total, 198 patients were randomized and 175 patients completed the trial with a mean age of 49.2 years. There was no clear benefit of active preparation with either P/MC or PEG over clear fluids only in the overall 5-point rating scale or in the distal fourth of each examination. There was no difference in diagnostic yield between groups. Significant differences were seen concerning tolerance of the preparations, with a higher proportion rating it as easy or very easy in the clear fluids–only group (93%) and the P/MC group (67%) than in the PEG group (13%) (P < .0001).
Small-bowel cleansing for VCE remains a controversial topic. This randomized control trial demonstrates no benefit in overall or distal small-bowel visualization with active preparation using either PEG or P/MC compared with clear fluids only. (Clinical trial registration number: NCT00677794.)
Capsule endoscopy (CE) usage and research in pediatrics is in its infancy but is growing. The possibility of avoiding ionizing radiation, deep sedation, and general anesthesia makes CE an appealing tool for diagnosis and disease state monitoring in luminal pediatric gastrointestinal disorders. As such, clinical use is expanding, but research has lagged behind, focusing on inflammatory bowel diseases (IBD) and polyposis syndromes. Food and Drug Administration approval in 2009 for children 2 years of age and older has resulted from the broader application of CE. In turn, this acceptability has fostered use in infants as young as 8 months (and 7.9 kg in weight). With these age differences (within the pediatric population and in comparison with adults), the indications have changed, with continued emphasis on not only patients with IBD but also in younger children who have a lower incidence of IBD, with more concern regarding occult bleeding and additional small bowel disorders, including graft-vs-host disease, Henoch-Schönlein purpura, cystic fibrosis, and lymphangiectasia. The ability to swallow or place the capsule remains a concern, but retention parallels adult indications rather than age. To date, esophageal capsules have been used primarily for the evaluation of varices, although the colon capsule has been used to further understand IBD in both the small bowel and the large bowel. With this varied and expanded use has come comparisons with other diagnostic modalities, attempts to integrate CE with these modalities into effective and cost-effective clinically assessed algorithms, and a plea for further research and the funding to make that possible.
Small bowel cleansing by capsule endoscopy has never been addressed in children.
Randomized controlled trial to evaluate the effect of five bowel preparation regimens on the mucosal visibility surface (as percentage of visualized surface area). Group A: a clear liquid diet for 12 h on the day before; Group B: high volume polyethylene glycol (50 mL/kg, up to 2 Lt/die); Group C: low volume polyethylene glycol (25 mL/kg up to 1 Lt/die); Group D: 20 mL (376 mg) of oral simethicone; Group E: 25 mL/kg (up to 1 Lt/die) of polyethylene glycol solution plus 20 mL (376 mg) of oral simethicone.
Overall, 198 patients (53% male, median age 13 years) were enrolled. Preparation regimen visualization scores were 14.1 ± 4.2, 18.9 ± 5.1, 17.8 ± 5.5, 14.9 ± 4.8 and 20.9 ± 4.6 in groups A, B, C, D and E, respectively (P < 0.01). Positive findings were found in 172 cases (87%), but no significant differences were observed in the diagnostic yield and tolerability. Interobserver agreement, k = 0.89 (95% CI 0.83 ± 0.71).
This is the first report in children that supports the use of 25 mL/kg (up to 1 Lt/die) of polyethylene glycol solution plus 20 mL (376 mg) of oral simethicone as the preparation of choice for capsule endoscopy.
Ning Dai and Christoph Gubler contributed equally to this work.
Grant support: Scholarship at the University Hospital of Zurich was sponsored by the China Scholarship Council (N.D.); Swiss National Foundation No. 32-66947.01 (P.B.)
