VCE provides a non-invasive way to visualize the small bowel. It has several accepted indications such as obscure GI bleeding, Crohn's disease, and celiac disease. VCE has advantages over other techniques as it can image the entire small bowel without risk of complications. Interpretation requires reviewing images to identify pathology. Safety concerns include capsule retention requiring endoscopic retrieval, so patients with strictures are not candidates. Future applications may include guided, self-propelled, or biopsy capsules to improve diagnostic abilities.

1. VCE
Hossam Ghoneim, MD

2. Outline
n Rationale
n Available VCE
technology
n Consensus statements
n Indications
n Safety concerns
n Future potentials

3. Small bowel – “black box” of the GIT
1 - limits of radiological investigations
- intestinal tumors:
SBFT < CT < Intestinal CT
- vascular lesions :
Radionuclide scan < arteriography
2 - limits of endoscopic investigations of the small bowel
- push enteroscopy: limit in the proximal jejunum & distal ileum
- intraoperative enteroscopy: invasive, morbidity ++
- D/B enteroscopy: invasive, long duration
Priority: endoscopic treatment

4. Videocapsule Technology
n ‘Given’ technology
n Dimensions:
26mm(L)x11mm(D)
n Weight: 3,45gr
n Field of view: 140°
n Magnification 1:8 (approx)
n 2 images per secound
n Operating time: 6-8 h
n Olympus technology
n High-quality image
comparable to high-
resolution videoendoscope
(CCD)
n Structure enhancement
n Light regulator
n External Viewer – ability to
check the exact capsule
position during the
examination (impaired
motility, obstructive lesions)

6. Olympus Technology

8. Preparation
n 12 hours fasting
n ? Colon prep.
n ? prokinetics
n Fitting sensors
n 7-8hr procedure time
n Oral liquid allowed 2hrs
after capsule ingestion,
food after 4hrs.

9. Interpretation
§ Selection and recording of the images and videoclips
§ Multi-viewing (dual endoscopic image) of video stream
§ Blood indicator function
§ Dynamic localization function
Interpretation requires 30 to 60 minutes
It needs good knowledge of digestive pathology
It needs an experience in interpretation of endoscopic images

10. Indications
n Accepted Indications
n Potential Indications

11. Accepted Indications
n Obscure GI bleeding
n Crohn’s disease
n Coeliac disease
n Hereditary intestinal polyposis syndromes
n NSAID enteropathy

12. Potential Indications
n Evaluation of indeterminate colitis
n Evaluation of small bowel transplants
n Alternative to f/up celiac disease after gluten free diet
n Screening or surveillance for malignances of small bowel in
patients at risk
n Evaluation of damage on small bowel mucosa by NSAID’s or
other drugs
n Evaluation of chronic abdominal pain

13. Obscure GI bleeding

14. n 5% of gastrointestinal bleeding of any type
n Valuable tool in the diagnositic tool kit
n Key advantages: ability to review and share images,
patient preference, safety profile, ability to conduct in
variety of settings, clarity of image comparable to other
endoscopy, ability to image entire small bowel
n CE should be part of initial investigation in patientes
with obscure bleeding without suspiction of obstruction

16. video

17. Suspected Crohn’s disease
Suspected Crohn’s disease
Colonoscopy
ileoscopy
Negative Positive
Obstructive
symptoms
Stop
Positive Negative
Capsule
Endoscopy
Other
modalities

18. Suspected Crohn’s disease
n More sensitive for assesing mucosal lesions than any
other small bowel technique
n Useful in suspction of Crohn’s disease and negative
endoscopic evaluation
n Evaluation of unexplain symptoms of patients with
known IBD
n Role in assessing mucosal healing after medical
therapy, evaluation of early post-operative recurrence

20. video

21. Coeliac disease
n Positive serology patients unwilling or unable
to undergo upper GI endoscopy
n Positive serology patients with negative
histology to rule out patchy disease
n For alarm symptoms in know CD patients on a
gluten free diet (risk of malignancy)

23. Hereditary Intestinal Polyposis
Syndroms
n FAP: Familial adenomatous polyposis
n PJS: Peutz-Jeghers syndrome
n FJP: Familial juvenil polyposis
n Hereditary nonpolyposis colorectal cancer

25. NSAID enteropathy
“NSAID Diaphragm”

26. VCE in Children
n VCE was superior to conventional studies
(gastroscopy, colonoscopy, and SBFT examinations)
to find lesions suggestive of Crohn’s disease in a
small study looking at patients between 12-16 yrs.
n VCE is an accurate and noninvasive approach for
diagnosing obscure small bowel lesions in children
over the age of 10.
n The safety issue may limit the use of VCE in the
younger age group given the fact that this group may
have difficulty passing the capsule through the
gastrointestinal tract, particularly the pylorus and
ileocecal valve.

27. Safety concerns
qCapsule Retention
§ anatomical stenosis
§ impaired peristalsis
§ impaired gastric emptying
qEndoscopic or surgical retrieval of entrapped
capsules has been required in a few cases
qNo complication has been reported due to
incidental leackage of the batteries or
exposure to the ingested batteries

28. qTo avoid the risk of blockade the capsule it is
necessary:
§ Take into account medical history of the
patient:
§ surgery, radiotional therapy, NSAIDs
§ Take into account contra-indications
§ Known or suspected gut strictures
§ Extensive Crohn Enteritis
§ Presence of numerous intestinal diverticuli

29. Future potential of VCE
n Capsule guidance
system
n Wireless power supply
system
n Self propelled capsule
n Drug delivery system
n Body fluid sampling
technology
n Ultrasound capsule

30. n Eso capsule (PILLCAM® ESO)
n Mainly in GERD, FDA following a study by Elikim et al
published in an abstract form . Sensitivity and
specificity for both indications was very high (100% &
80% respectively).
n Follow-up of the Barrett’s esophagus but no biopsy.
n Follow-up of the varices
(G.M.Eisen et al. Endoscopy 2006.; M.-G.Lapalus et al. Endoscopy 2006)
n Not reliable in comparison with modern
videoendoscopy (except for f/up GERD).

31. n Colon Capsule
n Preparation
§ Use of prokinetics?
§ The same preparation as for colonoscopy?
n Duration of the exam and life of the batteries
n Scientific studies very limited
n Problems to be solved
n Colonic lumen bigger than small bowel lumen

32. Take Home Message
n For your patient with
n Anaemia & both UGI & LGI endoscopy are
unrevealing
n Suspected CD But UGI & LGI are unrevealing
n Deteriorating course of coeliac disease
n You Have
VCE