Capsule Endoscopy:
A Revolution in the Endoscopic
Field
Dr. Md. Yasir Arafat
MRCP, MD, ESEGH
Sheikh Russel National Gastroliver Institute and Hospital,
Dhaka

1971
Sonde type
enteroscopy
1957
Fiberoptic
endoscopy
BY Mr. Basil
1969
Dr. William and
Dr. Hiromi-
fiberoptic
colonoscope
2001
Double balloon
enteroscopy
2001
Capsule
endoscopy-
opened the
black box
Evolution of fiberoptic endoscopy system

Capsule endoscopy: A revolution in the endoscopic
field

Capsule endoscopy: A revolution in endoscopic field
Allows physicians to visualize the entire gastrointestinal
tract from the esophagus to the colon.
No sedation required
Eliminates discomfort

Basic aspect CE

Song, Hyun & Shim, Ki-Nam. (2016). Current status and future perspectives of capsule endoscopy. Intestinal Research. 14. 21. 10.5217/ir.2016.14.1.21.
Technical aspect

Travel route
of capsule
endoscopy

Capsule Endoscopy system

https://youtu.be/tTyl5Dr9lnY

Preparation for small bowel capsule endoscopy
● SB-VCE- fasting or consumption of clear liquids for 10 to 12
hours is commonly recommended
○ ESGE recommends that prior to SBCE patients ingest a
purgative (2 L of polyethylene glycol [PEG]) for better
visualization.
● A diet of clear liquids is allowed after 2 hours from capsule
ingestion and a light meal after 4 hours
● Typical reading times vary between 30 and 120 minutes for SB-
VCE

● Bowel preparations for CCE-2 are intensive
○ A clear liquid diet is recommended on the day before the
procedure, and a split-dose 4-L polyethylene glycol
preparation is used
○ After the capsule enters the small bowel, an alert (Alert 1)
prompts all patients to ingest a “booster” of 6 ounces of
sodium sulfate/potassium sulfate/magnesium sulfate
(Braintree Laboratories, Braintree, Mass, USA) diluted to 16
ounces with water, followed by 1 L of water
American Society for Gastrointestinal Endoscopy (ASGE)

● ASGE guidelines state that readers of VCE should
have either undergone formal VCE training during
fellowship or have completed a formal GI- or surgical
society-endorsed training course with proctoring of
the first 10 capsule readings
American Society for Gastrointestinal Endoscopy (ASGE)

Indication of Small Bowel-VCE
● Evaluation
of both
overt and
occult
small-
bowel
bleeding
VCE in hereditary haemorrhagic telangiectsia
VCE during active bleeding
at terminal ileum

● Suspected,
known, or
relapsed CD
when
ileocolonosco
py and
imaging
studies were
negative
Indication of Small Bowel-VCE

● Surveillan
ce of
polyposis
syndrome
s
Indication of Small Bowel-VCE
(García-Márquez, J. & Damas, M. & Caballero Mateos, Antonio. (2020). Video capsule endoscopy in the diagnosis of Peutz-Jeghers syndrome. Revista
de Gastroenterología de México (English Edition). 85. 10.1016/j.rgmxen.2019.10.003.)

● Suspected
small
intestine
tumours
Indication of Small Bowel-VCE

● Suspected or
refractory
malabsorptive
syndromes (eg-
celiac disease,
lymphangiectasia
)
Indication of Small Bowel-VCE
 Villous atrophy in
celiac disease-
Subtotal to total
atrophy Marsh class
iii-iv (a)
 Marsh class ii (b)
 normal (c &d)
 Scalloping, fissure
and mosaic mucosal
pattern in VCE (a)
and enteroscopy (b)

Lymphangiectasia with mucosal oedema and a whitish patch of villi
Indication of Small Bowel-VCE

Meta-analysis on SB-VCE Vs DBE
● Overall yield was not statistically different
SB-VCE (60%, n = 397) and DBE (57%, n =360)
Clinical Gastroenterology and Hepatology Volume 6 Issue 6 Pages 671-676 (June 2008) DOI: 10.1016/j.cgh.2008.01.005

VCE Vs CT
● VCE- better for detecting ulcers, enteritis, and
angiodysplasia
● CTE- more sensitive in detecting tumors and Meckel
diverticula
American Society for Gastrointestinal Endoscopy (ASGE)

Colon VCE
PillCam COLON 2 and PillCam Crohn’s- FDA approved
● Detection of colon polyps in patients with evidence of GI bleeding of
lower GI origin- In a meta-analysis of 7 studies (n = 1292) that used the CCE-2 system,
the sensitivity for polyps >6 mm was 86.0% and specificity was 88.1%
● PillCam Crohn’s has been cleared by the FDA for visualization of the
small bowel and colonic mucosa
American Society for Gastrointestinal Endoscopy (ASGE)

Upper GI VCE
The PillCam UGI capsule (Medtronic, Minneapolis, Minn,
USA)
● For esophagus and stomach
○ patients who either refuse or are otherwise unable
to undergo OGD
■ suspected Barrett’s esophagus (BE)
■ reflux esophagitis
■ esophageal varices
● Battery life is only 90 minutes
American Society for Gastrointestinal Endoscopy (ASGE)

PillCam Patency capsule
● Patency capsule has
similar dimensions (11.4
mm 26.4 mm)
● At 30 hours, time-
controlled plugs at the
ends of a retained
capsule erode, allowing
intestinal fluids to
dissolve the capsule
body
Patency capsule: a. Intact b. Without
tag c & d. After degradation

Patency capsule indicator blue light and presence of tag in X-ray
PillCam Patency capsule

a) Intact patency capsule 24
hours after ingestion
b) Patency capsule tag presence
after 50 hours. VCE therefore
contraindicated
c) Presence of tight stricture in
CT
d) Impassably tight jejunal
stenosis with ulcer at
enteroscopy
PillCam Patency capsule

● Presence of patency
capsule tag after 65
hours (a)
● CT shows a stricture at
ileum (b)
● After surgery, small
bowel adenocarcinoma
with stricture with
remnant of patency
capsule is found (c)
PillCam Patency capsule

Contraindication of SB-VCE
● Known or suspected intestinal
obstruction, strictures, or fistulas
● ? Presence of pacemakers,
defibrillators(ICD), or left
ventricular assist devices(VAD)
○ ESGE recommends that
patients with pacemakers,
ICD, VAD, can safely
undergo SBCE without
special precautions
Stenosis and two retained Video capsules
Pacemaker and ICD

● ?MRI is anticipated within 1 week of capsule ingestion
(Acc. Manufacturer instruction)
● Swallowing disorders to avoid aspiration- Endoscopic
placement is an option
● Pregnancy- adequate safety data is not available
Contraindication

Adverse events
● Capsule retention (1.4%)
○ CD (35.3%)
○ ESGE recommends observation in cases of asymptomatic
capsule retention
● Intestinal perforation- Exceedingly rare (only two case
reports to date)
● Capsule aspiration (0.1%)
American Society for Gastrointestinal Endoscopy (ASGE)

Disadvantage of VCE Promising solution
Incomplete small bowel
examination
Low-quality image Chromoendoscopy and 3D
reconstruction
Uncontrolled air insufflation Controlled CO2 insufflation
Retention or delayed transition External real-time image viewer
Limited battery life Frame rate modulation and Video
compression

Other disadvantage of VCE
● Impossibility of maneuver
● Therapeutic or biopsy capability
● Delayed time of the interpretation

● (A) A capsule that emits
magnetic force
● (B) A capsule with legs for
mucosal ambulation
● (C) A capsule that involves
use of a paddling stroke
● (D) A capsule with four
propellers
Promising solution

Summary
● VCE allows a minimally invasive approach
● VCE- a first-line approach in the evaluation of small-
bowel bleeding
● It is an emerging modality in the evaluation of disease
severity of CD
● CCE is an emerging screening modality for the
detection of colorectal neoplasia for those unable or
unwilling to consider colonoscopy for screening