Assistant Professor of Medicine. University of Marylan

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Wireless Capsule Endoscopy In Crohns Disease

• Eric Goldberg, M.D.
• Director of VA GI Endoscopy
• Assistant Professor of Medicine
• University of Maryland Medical Center
• November 19th, 2005

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Capsule Endoscopy for IBD

• SS is a 40 year old male with a past medical
  history of ulcerative colitis s/p total
  proctocolectomy with ileostomy for dysplasia.
  Post operative course complicated by an SBO
  requiring small bowel resection.
• SS did well for 11 years following his colectomy
  but then developed bright red blood in his
  ileostomy bag and abdominal pain.
• Ileoscopy Normal
• EGD Normal
• SBFT Normal

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Small Bowel Follow Through
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Evaluation of the Small Intestine

• Push Enteroscopy
• 2.5meter long push enteroscopy
• Sonde and rope-way enteroscopy
• CT Enterography
• Small Bowel MRIs
• Intra-operative enteroscopy
• Double Balloon Enteroscopy

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The Capsule

• Diameter 11mm Length 26mm
• Optical dome Intestinal illumination by white
  light emitting diodes (LEDs)
• Lens
• Complementary metal-oxide silicone imager (color
  camera chip)
• Transmitter
• Two batteries (silver oxide)

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Features of the Capsule

• Capsule takes two images per second
• On average, 50,000 images are obtained during an
  8 hour exam
• Magnification 8x
• Capsule coating non-adherant
• Disposable

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Physiologic Endoscopy

• Bowel is visualized in its normal state
• No scope trauma
• Air insufflation not a factor
• Exam can be performed on anticoagulation

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GE Junction
Duodenum
Jejunum
Ileocecal Valve
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Phlebectasia
AVM
Lymphangectasia
Bleeding Lesion
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Lymphoma
GIST
Polypoid Mass
Polyp
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NSAID stricture
Radiation Enteritis
Sprue
Villous Drop Out
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Performance

• Overnight 12 hour fast
• Sensors placed on patient
• Patient wears a belt that contains a battery pack
  and data recorder.
• Patient ingests capsule around 8am
• Patient may have clears two hours after ingestion
• Patient may have a light lunch 4 hours after
  ingestion
• Avoid other patients who ingested a capsule.
• Patient returns 7-8 hours later

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Indications

• Obscure gastrointestinal bleeding
• Evaluation of extent of small intestinal
  disorders such as Crohns disease or Celiac sprue
• Abnormal small intestinal imaging
• Suspected malabsorption
• Surveillance of polyposis syndromes involving
  small intestine

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Complications

• Retention of capsule 1-5
• Bowel obstruction .5
• Aspiration Rare

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Contraindications

• Absolute
• Suspected small intestinal obstruction
• Pacemakers/AICDs.
• Pregnancy
• Relative
• Motility disturbances Gastroparesis/Achalasia
• Small bowel diverticulosis
• Poor surgical candidates

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Informed Consent

• WCE does not replace examination of the stomach
  or colon
• Risk includes bowel obstruction that may require
  surgery
• No MRIs until capsule has passed
• May not visualize the entire small bowel

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Average Transit Times

• Stomach One hour
• Small Intestine 4 hours
• Capsule Passage 2-3 days

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Reading the Study

• Reading times can vary from 20 minutes to 2 hours
• Can read up to 25 frames/sec. I recommend 12-15
  frames/second
• Gadgets to speed reading times
• Red finding software
• Double frame imaging
• Quad view

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Why Perform Wireless Capsule Endoscopy for IBD?

• Diagnosis
• Differentiate UC from Crohns disease
• Different natural history
• Different medical and surgical therapies
• Evaluate extent of small intestinal involvement
• Determine disease activity

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Subtle Findings

• White tipped villi - a sign of inflammatory or
  infiltrative change
• Q-tip lesion

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Ileitis
Inflammatory polyp
Crohns disease
Linear Erosions
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Capsule Endoscopy for Initial Diagnosis of
Crohns Disease Literature Review

• Four prospective, comparative trials evaluating
  capsule endoscopy for suspected Crohns disease
• Yield as high as 70 if typical symptoms and
  abnormal inflammatory markers (CRP, ESR)
• Yield low (lt10) if diarrhea or abdominal pain in
  absence of inflammatory markers/signs.

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Capsule Endoscopy is Superior to SBFT For the
Evaluation of Crohns Disease

• Author N SBFT Yield CE Yield
• Scapa 2002 13 0 46
• Fireman 2003 17 0 71
• Herrerias 2003 21 0 43
• Hara 2005 17 0 71
• Mow 2004 50 32 60
• Arguelles 2004 12 0 59
• SantAnna 2005 20 0 60

Patients with strictures by SBFT were excluded
likely accounting for low yields of SBFT
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Capsule Endoscopy Versus Other Imaging Modalities
for Crohns Disease

• Study Yield
• Capsule vs Ileoscopy 61 vs 46
• Capsule vs Push enterosc 51 vs 7
• Capsule vs CT enterography 75 vs 37
• Capsule vs Small bowel MRI 60 vs 40

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Safety of Capsule Endoscopy in Crohns Disease

• Author Patients Capsule Retention
• Mow 50 4
• Herrerias 21 0
• Fireman 17 0
• Eliakim 20 0
• SantAnna 20 5
• Buchman 30 6.7

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Safety of Capsule Endoscopy in Crohns Disease

• Recommendations
• Obtain SBFT prior to CE in patients with known
  Crohns disease to r/o high grade stricture
• Patency capsule?
• Discuss and document risks with patients prior to
  capsule
• Double Balloon Enteroscopy for capsule removal

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Problems with Current Studies on CE and Crohns
Disease

• No gold standard diagnostic test to compare
  capsule with
• Criteria for diagnosing Crohns by capsule
  endscopy
• Specificity too high?

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Patient

• XX is a 32 year old female with a history of
  Crohns disease for ten years. Eight years ago,
  she underwent a terminal ileal resection with an
  ileo-transverse colon anastomosis.
• For the past 6 months, she was experiencing 4-6
  loose stools per day and mid abdominal pain. She
  denied obstructive symptoms such as nausea,
  vomiting or obstipation.
• She was being treated with pentasa 3 grams/d and
  enterocort
• Laboratory evaluation was significant for an ESR
  of 55
• A SBFT was normal
• A colonoscopy was normal to the terminal ileum

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Proposed Algorithm For Diagnosis of Suspected
Crohns Disease

Colonoscopy/Ileoscopy
Stop
_
Obstructive Symptoms?
_

Capsule Endoscopy
SBFT

_
Stop