Current practice and future directions of capsule endoscopy technique

1. By
Ahmed Abudeif Abdelaal
Assistant Lecturer of Tropical Medicine & Gastroenterology
Sohag Faculty of Medicine
February, 2016
Capsule Endoscopy

2. History of Endoscopy
- The first real endoscope that was developed was made by
Phillip Bozzini in 1805 to examine the urethra, the bladder and
vagina.
Bozzini Lichtleiter

3. History of Endoscopy
- Adolf Kussmaul in 1868 used a straight rigid metal tube over a
flexible obturator to perform the first gastroscopy.

4. History of Endoscopy
- Building on the work of others, Wolff Schindler constructed
the first practical gastroscope in 1932.

5. History of Endoscopy
- In 1957 Basil Hirschowitz developed his prototype fiberscope.

6. Introduction
- Capsule endoscopy (CE) was first used in humans in 1999.
- A commercially available capsule was approved by FDA in
August 2001.
- Since its introduction into clinical practice CE has established
itself as an invaluable tool for investigating a wide variety of
gastrointestinal diseases.

7. Technical aspects
- Two major companies have CE products:
• Given imaging (Yoqneam, Israel) has the PillCam.
• Olympus (Tokyo, Japan) has the EndoCapsule.
- Other CE devices available in the market:
• Mirocam (Intromedic, South Korea).
• OMOM pill (Chongqing, China).

8. Technical aspects
- CE system consists of 3 components:
1) Capsule itself.
2) Data recorder attached to aerial leads which are taped to
patient’s abdominal wall.
3) Dedicated computer with software for downloading and
analyzing the images from the data recorder.

9. Capsule
endoscopy
system

10. Technical aspects
- The capsule consists of:
1) Optical dome.
2) Lens holder.
3) Lens.
4) 6 illuminating LED’s (Light emitting diode).
5) Complementary metal oxide silicon (CMOS) image sensor.
6) 2 silver oxide batteries.

11. Technical aspects
7) Application specific integrated circuit (ASIC) transmitter.
8) Antennae.

12. Specifications of capsule endoscopies present in the market

13. Capsule endoscopy procedure
- Capsule is initially stored in a case containing a magnet that
inhibits its activation. Once it taken out of the case, the LEDs
start to flash and the capsule start to transmit.
- 8 aerial leads are taped to the patient’s anterior abdominal
wall to collect data sent by the capsule.
- A recorder connected to battery worn on a belt is attached to
the leads.
- Capsule ingested as any other capsule.

14. Capsule endoscopy procedure
- Drinking clear liquids is allowed after 2 hours and a light meal
after 4 hours of capsule ingestion.
- Patient is allowed to continue with their normal daily activites.
- Patient returns 8 hours later or when the recorder stop
recording.
- Images are downloaded on dedicated computer and
processed prior to interpretation.

15. Small bowel preparation before Capsule endoscopy
- Clear liquid diet the day before the procedure.
- An overnight (8-12 hours) fast.
- Administration of 2 L PEG based purge one day before the
procedure. Addition of simethcone to the purge to reduce
bubble formation.

16. Colonic preparation before Capsule endoscopy
- Clear liquid diet the day before the procedure.
- On the evening before the procedure, patient ingest 3 L of
PEG and an additional 1 L, 2 hours before capsule ingestion.
- Immediately before capsule ingestion, 20 mg of domperidone
is administered orally.
- 2 hours after capsule ingestion, 45 ml of sodium phosphate
solution is administered orally.

17. Esophageal preparation before Capsule endoscopy
- Fasting for 2 hours.
- The patient drinks 100 ml of water while standing ,ingests the
activated capsule in supine position with a 10 ml sip of water.
- A 2 minute recording with the patient supine, 2 minutes raised
to 30°, additional minute at 60°, followed by an upright position
for 15 minutes.

18. Indications of CE
A) Small bowel CE:
1) Obscure GIT bleeding.
2) Crohn’s disease (diagnosis, evaluation of disease activity).
3) Coeliac disease (diagnosis, evaluation of refractory
disease).
4) Small bowel tumours.
5) Polyp surveillance in polyposis syndromes (FAP, Peutz-
Jeghers syndrome).

19. Indications of CE
A) Small bowel CE:
6) Surveillance for graft rejection after small bowel transplant.
7) Detection of graft versus host disease.
8) Unsolved abdominal pain / diarrhoea.

20. Indications of CE
B) Esophageal CE:
1) Screening for esophageal varices.
2) Screening for Barrett’s esophagus.
3) Detection of esophagitis.

21. Indications of CE
C) Colonic CE:
- Until now, there is high degree of uncertainty regarding
clinical indications.
1) Polyp detection.
2) Incomplete colonoscopy.
3) Patients refusing colonoscopy.
4) ? Screening for colorectal cancer and follow up evaluation
for ulcerative colitis.

22. Lesions at CE
seen in patients
with obscure
GIT bleed
A: Arteriovenous
malformation
B: NSAID ulcer
C: Polyp
D:
Adenocarcinoma
E: Hook worm
F: Small
intestinal varix
BA
D
C
FE

23. Crohn’s disease
by capsule
endoscopy
Fissuring Multiple aphthous ulcers
Stricture
Serpiginous ulcer
Cobble stoning

24. Endoscopy images.
A: Multiple angioectasia.
B: Metastatic malignant melanoma of the
small bowel.
C: Ulceration due to Crohn’s disease-deep
ulcer indicated by arrow.
D: Circumferential ulceration and stenosis
due to NSAID use.
E:Typical mucosal changes associated with
coeliac disease.
F: Enteropathy associatedT-cell
lymphoma.
G: Peutz Jeghers syndrome.
H: Oesophageal varix with associated
regenerative nodule.
I: Colonic polyp.
J: Colorectal adenocarcinoma.
BA
E
C
D
G
F
H I
J

26. Complications of CE
1) Capsule retention: (1-2%)
- Many conditions increase the risk of retention including
Crohn’s disease (4-13%), radiation enteritis, suspected small
bowel strictures and tumours, recent abdominal surgery and
history suggestive of small bowel obstruction.
- Capsule retention is often associated with the identification of
significant pathologic findings that often require further surgical
or endoscopic intervention.

27. Complications of CE
1) Capsule retention: (1-2%)
- The use of patency capsule (Agile patency system, Given
imaging), can reduce the risk of retention and it should be used
in patients with suspected strictures prior to endoscopy.
A BCapsule
retention at
stricture.
A: Stricture seen
at capsule
endoscopy.
B: X-ray
showing the
retained capsule
(red circle).

28. Complications of CE
- Patency capsule:
- It is a disintegrating, time controlled system with RF
identification (RFID) tag and RFID scanner.
- It is of same dimension as real capsules but has a cellophane
wall filled with mixture of barium and lactose and RFID at its
center. The presence of barium makes it detectable also by X-
ray.
- The lactose filling of capsule dissolves after 40 hours leading
to collapse of outer membrane, which is then excreted.

30. Complications of CE
2) Capsule aspiration into tracheobronchial tree. Occurs in
patients with associated swallowing disorders.
3) Capsule impaction at the cricopharyngius.
4) Capsule retention in Zenker’s or Meckel’s diverticulum.
5) Theoretical risk of electromagnetic interference with cardiac
pacemakers and ICD.

31. Contraindications of CE
1) Presence of known intestinal strictures, fistulas or
obstruction.
2) Small children.
3) Pregnant females (due to lack of safety data).
4) Patients with swallowing disorders.
5) ? Presence of pacemakers, ICD.

32. Limitations of CE
1) Poor visualization of areas of the mucosa due to quick
passage (avoided by adjusting frames).
2) Inability to insufflate.
3) Tangential views and debris.
4) Lack of biopsy.

33. Technical improvements
1) Improved quality of lenses and adaptive illumination allow a
wider angle of view and enhanced picture clarity.
2) The CapsoCam (Capso Vision Inc, Saratoga, United States)
has four side-viewing (as opposed to end-viewing) lenses
allowing a 360° panoramic view to improve mucosal
visualisation.
CapsoCam

34. Technical improvements
3) Recently introduced data recorder has a screen which can
show real time images during ongoing examination. This has
shortened the duration of examination, as the procedure may
be terminated once cecum is visualized at real time. Also,
water and metoclopramide can be administered if capsule
transit is delayed.

35. Technical improvements
4) Chromoendoscopy (Fuji intelligent colour enhancement,
FICE). FICE enhances surface contrast in three specific
wavelengths (red, green and blue) and appears to improve the
definition and surface texture of small bowel lesions already
detected with white light.
- Whether this actually influences detection rates or clinical
outcomes still remains uncertain.

36. Ulcerated lesion at capsule endoscopy using chromoendoscopy.
A:White light.
B: Blue light (with Fuji intelligent color enhancement, FICE).
A B

37. Technical improvements
5) Updates in software:
A. Viewing the images at variable speed almost like a video.
B. Introduction of localization site (for detection of lesion site),
automated tumour detection software algorithms, blood
detector (for identifying site of bleeding), double and quadri-
viewer.
C. Quick view reduces the time required for image reading to
less than 10 minutes by selecting 2-80% of frames,
producing a condensed video for review.

38. Technical improvements
5) Updates in software:
D. Calculation of scoring systems (inflammation, polyp,...) and
comparing images with incorporated atlas.
E. Reconstruction of 3D images from CE 2D image has been
trialled. It improves visualisation of a significant proportion of
vascular lesions but, surprisingly, was less beneficial for
inflammatory and protruding lesions.

39. Future directions
1) Remote control:
- Present capsules moves in GIT with peristalsis which can
lead to incomplete evaluation of bowel.
- Swain et al first reported the possibility of controlling the
movement of capsule by an external hand held magnet. This
technique has been further refined by using a robotic magnetic
navigator system manipulated by joystick.
- By this technique, the capsule can be easily manipulated in
the esophagus and stomach.

41. Future directions
2) Maneuverable capsules:
- Several prototypes of self-propelled capsules (using fins, legs
or a self-contained propeller) have recently been evaluated in
an attempt to allow capsules to navigate and stabilize in areas
of interest allowing for careful inspection, targeted biopsy and
even drug delivery. Furthermore, a steerable capsule could
overcome the problems encountered in examining capacious
stomach.

42. The Spider Pill an endoscopic
capsule robot
A pill-sized capsule robot
capable of performing tissue
biopsies and dispensing drugs
Intestinal robot

43. Future directions
3) Battery-less capsule:
- In order to overcome the limited battery life as well as for
more liberal rate of image acquisition, attempts have been
made to supply power to the capsule by an external source
with a wireless transmission.