Capsule endoscopy in gastrointestinal disease: Evaluation, diagnosis, and treatment

Basil Akpunonu; Jeannine Hummell; Joseph D. Akpunonu; Shahab Ud Din

doi:10.3949/ccjm.89a.20061

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Figure 1
Capsule endoscopy of the small bowel. A, normal; B, diverticula; C, angiodysplasia; D, erosions of Crohn disease; E, a 10-mm pedunculated polyp; and F, ulcerative colitis.
Used with permission of Annals of Translational Medicine, from Toth E, Yung DE, Nemeth A, Johansson GW, Thorlacius H, Koulaouzidis. A Video capsule colonoscopy in routine clinical practice. Ann Transl Med 2017; 5(9):195. doi:10.21037/atm.2017.03.91. Permission conveyed through Copyright Clearance Center Inc.

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TABLE 1

Current indications for capsule endoscopy in adults

In the small bowel
Finding the source of obscure gastrointestinal bleeding

Evaluating iron-deficiency anemia in which a gastrointestinal source is suspected and upper and lower endoscopy are negative

Crohn disease: diagnosis and surveillance of disease activity

Celiac disease: diagnosis and evaluation of refractory disease

Assessing mucosal healing

Surveillance of polyposis syndrome

Diagnosing small-bowel tumors

Detecting arteriovenous malformation

Evaluating drug-induced injury, eg, from nonsteroidal anti-inflammatory drugs

In the esophagus^{^a}
Diagnosing Barrett esophagus
Diagnosing variceal bleeding

In the colon
Screening in cases of incomplete colonoscopy
Screening in patients at high risk from sedation, pain medications, and anesthetics

↵a Capsule endoscopy is used if upper-gastrointestinal endoscopy cannot be tolerated.

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TABLE 2

Contraindications to capsule endoscopy for small-bowel disease

Cognitive disorders in which the patient may not follow instructions for the procedure, resulting in biting the capsule, damaging teeth or the capsule

Gastroparesis (but the capsule can be placed distally with an endoscope)

Esophageal stricture or swallowing disorders (but the capsule can be placed endoscopically)

Zenker diverticulum of the esophagus

Partial or intermittent small-bowel obstruction, chronic adhesions

History of strictures from inflammatory bowel disease

Pregnancy

Active Crohn disease

Left ventricular assist devices (but pacemakers and automatic implantable cardiac defibrillators are no longer contraindicated)

Numerous diverticula

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TABLE 3

Advantages of capsule endoscopy

Can directly visualize areas of gastrointestinal tract not easily reachable with fiberoptic endoscopy

Convenient for patients, with no loss of work hours

No bowel preparation needed for the most upper gastrointestinal studies

No need to withhold crucial medications

Minimal to no fasting

Inexpensive

No sedation or pain medications needed

No restriction for cardiopulmonary conditions (except concerns for cardiac devices)

Fewer complications such as bleeding or perforation

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TABLE 4

Canadian Association of Gastroenterology consensus recommendations for and against capsule endoscopy^{^a}

For gastrointestinal bleeding, capsule endoscopy is recommended:

In patients with documented overt gastrointestinal (GI) bleeding (excluding hematemesis and negative findings on high-quality upper-GI endoscopy and colonoscopy)

As soon as possible in patients with an overt, obscure bleeding episode

Possibly as part of a repeat study (with endoscopy or colonoscopy) in patients with previous negative capsule endoscopy results who continue to have obscure bleeding

In selected patients with suspected obscure GI bleeding and unexplained mild chronic iron-deficiency anemia

For celiac disease, capsule endoscopy is recommended:

In patients with unexplained symptoms despite treatment and appropriate investigations

… But capsule endoscopy is discouraged:

To make a diagnosis in patients with suspected celiac disease

For Crohn disease, capsule endoscopy is recommended:

In patients presenting with clinical features consistent with Crohn disease and negative ileocolonoscopy and imaging studies

In patients with Crohn disease and clinical features unexplained by ileocolonoscopy or imaging studies

In patients with Crohn disease, when the assessment of small-bowel mucosal healing (beyond the reach of ileocolonoscopy) is needed (conditional recommendation)

In patients with a suspected small-bowel recurrence of Crohn disease after colectomy, undiagnosed by ileocolonoscopy or imaging studies

For polyposis, capsule endoscopy is recommended:

For ongoing surveillance in patients with polyposis syndromes who require small-bowel studies (conditional recommendation)

For colon studies, capsule endoscopy is discouraged:

As a routine substitute for colonoscopy

As a substitute for colonoscopy in patients with inflammatory bowel disease to assess the extent and severity of the disease

↵a The strength of these recommendations is strong, except for the 2 conditional recommendations noted. However, the quality of evidence is low or very low for all.
Based on information in reference 6.