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Capsule endoscopy (CE) was first approved as a diagnostic tool for small bowel imaging in year 2000 in the United States.1 At that time the small bowel was considered a particularly difficult area to examine and the imaging modalities used included sonography, computed tomography (CT), enterography (CT/MR), enterocylis and push enteroscopy. Apart from the potential for complications, these modalities have a low diagnostic yield.2Subsequent studies have now established CE as the gold standard for small bowel imaging.3The procedure is painless, does not require sedation, is easy to perform and for the first time enables exploration of the entire small bowel at high magnification. Oesophageal and colonic capsule endoscopies have also been recently introduced for imaging the upper and lower gastrointestinal (GI) tracts respectively.4,5The two main clinical areas where CE has made a significant impact are in the diagnostic workup of patients with obscure GI bleeding and those with suspected small bowel inflammation mainly due to early Crohns disease. The former include patients with overt or occult GI bleeding with normal upper and lower endoscopies.6 The latter include patients with chronic diarrhoea with a clinical and laboratory setting suggestive of small bowel inflammation/ulceration (high inflammatory markers and high faecal calprotectin levels) rather than irritable bowel syndrome.7The role of small bowel CE has also been explored in other clinical settings including non specific abdominal pain, unexplained weight loss, suspected celiac disease and for surveillance in patients with small bowel tumors.8-11In New Zealand (NZ) small bowel capsule endoscopy has been introduced in all tertiary and a few of the secondary centres. To date, no data has been published from these centres apart from an abstract publication in 2009 from Waikato Hospital.12 We present our 2-year experience with 122 consecutive patients from a single centre in New Zealand.Patients and Methods This is a single centre, retrospective study, of 122 consecutive patients referred for small bowel capsule endoscopy to our unit from December 2009 to December 2011. All patients had previously undergone diagnostic procedures including gastroscopy, colonoscopy and CT or MRI examinations. Each patient was given a study leaflet explaining the nature of the procedure and an informed consent was signed. Routine history and physical examination was not performed on the day of the procedure. All outpatients had a bowel preparation with 2 litres of polyethylene glycol and started on clear fluids from the afternoon before the procedure. Metoclopramide, in oral dosage of 10mg was routinely given before the study. Inpatient were not routinely given prokinetics or bowel lavage but were given at the discretion of the requesting gastroenterologist. Clear fluids were started 2 hours after the capsule ingestion and a light snack given at 4 hours. Normal dietary habits were resumed after 8 hours. The bowel preparation in the study was graded as good, fair, or poor depending upon the adequacy of the examination. Any light contamination impairing views was also recorded. A patency capsule was administered first before the study in patients with suspected small bowel strictures. A CE placement device was used to deliver the capsule in patients with swallowing difficulties and those with gastroparesis. Contraindications to the study included patients with known intestinal strictures and those presenting with clinical and radiological evidence of small bowel obstruction. Patients were grouped according to their main presentation. Patients with obscure GI bleeding were stratified into those with overt bleeding and those with occult bleeding, either with accompanying iron deficiency anaemia or a low ferritin/FOB positive stool test. Patients with chronic diarrhoea (including those with suspected Crohns disease) and those with chronic non specific abdominal pain were classed separately. All other presentations including weight loss, suspected GI malignancy and suspected celiac disease were grouped together in the Other category. All the studies were performed by our endoscopy nurses according to the current protocol of our unit. The Given Imaging Diagnostic System (Given Imaging Ltd, Yogneam, Israel) was used; it involves the pillcam capsule, a data recorder worn by the patient during the study, and a work-station used to process and analyse the images using the Rapid 6 Reader software. Each study was read independently by two of the three gastroenterologists with expertise in the procedure. The CE images of the oesophagus, stomach and the colon were also read. The results were discussed and a combined report was later written. Data for the study was collected from the patients clinical, laboratory and radiology records and the Rapid 6 Reader software. CE findings in the study were classed as: Relevant - if they accounted for the patients presentation, e.g. vascular ectasias in a patient with iron deficiency anaemia or fresh blood in the lumen in patients with overt bleeds; Significant - if they were not relevant to the clinical presentation but still important to be noted, e.g. ulcers, polyps or neoplasms; and Normal - this class included those with a normal study and also those with insignificant findings (e.g. venous lakes, prominent vessels, prominent mucosal folds, submucosal bulges, red spots etc). Cases with relevant/significant findings in the Upper GI tract or colon but missed on prior endoscopies were also recorded. If more than one lesion was found during a study, then only the most relevant lesion was counted. In our study ulcers and aphthous ulcers were counted together, separate from erosions and fresh blood in the lumen was counted as a relevant finding. The completion status of the study was classed as Complete - when the capsule reached the caecum and Incomplete when either the capsule did not leave the stomach or failed to reach the caecum. A plain abdominal X-ray was taken if the patient did not report passing out the capsule 5 days after ingestion. A comparative analysis of CE findings was made, both with the imaging studies (barium/CT or MR Enterography) done up to a year before the CE examination for the same indication and with the faecal (calprotectin) and plasma (CRP) inflammatory markers done prior to the CE study. Procedure-related complications and post CE procedures recommended by the reporting gastroenterologist were also noted. Results Table 1 shows the indications for referral according to the gender, age category and inpatient status of the examination. The status of bowel preparation in different indications is also noted. The most common indication for referral was obscure GI bleeding (70%, N=86) which was sub-classified into overt bleeding (n=33), iron deficiency anaemia (n=39) and those with no anaemia but low ferritin (n=14). Patients referred with predominant diarrhoea, for workup for suspected enteropathy (n=18) and patients with non-specific abdominal pain (n=10) were the other significant groups. Rare indications, including suspected celiac disease and studies in Peutz Jegher patients were grouped into the other category. Table 1. Summary statistics, acuity status and bowel preparation Variables Obscure GI bleed (N=86) Predominant diarrhoea Abdominal pain Other indications Overt Occult Anaemia Low ferritin (N=18) (N=10) (N=8) Gender Male Female 25 8 19 20 6 8 6 12 5 5 2 6 Age <40 years 40-75 years >75 years 2 17 14 4 26 9 0 12 2 3 10 5 8 2 0 2 5 1 Acuity Outpatients Inpatients 14 19 39 0 14 0 16 2 7 3 7 1 Preparation Good Fair Poor 21 11 1 29 9 1 9 5 0 14 4 0 6 4 0 5 2 1 In our study 69% of the studies had good preparation, 29% had fair preparation while the rest had poor preparation. Light contamination, causing suboptimal views was noted in five patients (4%). No relationship was noted between the quality of preparation and the indication for the procedure. Inpatient CE examination were carried out in 25 (20%) patients. Nineteen of them were for overt bleeds. The diagnostic yield improved with inpatient examination in only the sub-group with overt bleeds (up to 74%). In the non-GI bleed studies only one out of the six patients with inpatient study had relevant findings. Majority of the inpatient examinations were carried out in male patients (76%). This was because presentation with overt bleeds was significantly more common in males (70%). The overall diagnostic yield of CE studies for findings relevant to the clinical indication in our study was 52%. Relevant gastric and colonic findings, picked on CE examination but missed on prior endoscopy were 2% and 6% respectively. Table 2 shows the influence of gender, age, inpatient status and indication for referral on the diagnostic yield of the study. Highest yield was seen in patients referred for overt bleeds (66%) and lowest yield in those referred for non-specific abdominal pain (8%). The total diagnostic yield (small bowel, stomach and colon) of relevant/significant findings was more in inpatients (75%) and the elderly (80%) but was not affected by the gender of the patient. Table 2. Diagnostic yield by gender, age, acuity and indication Variables Relevant and significant findings Normal and insignificant findings Gender Males Females 41 34 22 25 Age category <40 years 40-75 years >75 years 7 43 25 12 29 6 Acuity Outpatients Inpatients 56 19 41 6 Indication Overt bleeds Anaemia Low ferritin Diarrhoea Abdominal pain Others 27 27 7 12 2 1 6 12 7 6 8 7 We only calculated the frequency of specific findings in those studies where the findings were relevant/significant to the indication for the study. If more than one finding was reported, then the most relevant/significant finding was counted. Overall angioectasias (36%) and ulcers/apthous ulcers (32%) were the most frequent specific findings (Figure 1). For specific indications, the most frequently reported specific finding in those with overt bleed was fresh blood in the lumen (38%), and angioectasia (35%), in iron deficiency was angioectasia (52%), and in those with predominant diarrhoea was ulcer (75%). Figure 1. Frequency of relevant/significant findings GAVE= Gastric Antral Vascular Ectasias. Barium and CT/MR studies of the small bowel were done in 19 cases (16%), mainly in those with indications other than suspected GI bleeds (Table 3). Findings were consistent with the CE findings in 12 cases (63%) and false negative in seven cases (37%). No false positive cases were reported. As shown in the Table 3 most studies were done for cases presenting with predominant diarrhoea, where both the concordance and the false negative rates were 50%. CRP and faecal calprotectin measurements were also recorded in the subgroup of patients presenting predominantly with diarrhoea and non-specific abdominal discomfort (data not illustrated). In those with predominant diarrhoea, faecal calprotectin was raised in all but one case (when measured) compared to CRP levels which were recorded as normal in 56% (9 out of 16 measured) of the cases. However, the faecal calprotectin levels correlated correctly with CE findings in only 64% of the cases. In five cases (35%) the faecal calprotectin was falsely elevated, that is, the levels were significantly raised but the CE examination was unremarkable. Table 3. Preliminary imaging Variables Obscure GI bleeds Predominant diarrhoea Abdominal pain Other indications Overt Occult Anaemia Low ferritin Imaging not done concordant false negatives false positives 32 0 1 0 36 3 0 0 14 0

Summary

Abstract

Aim

Small bowel capsule endoscopy (CE) has been introduced in New Zealand (NZ) in all of the tertiary and some secondary centres over the last few years. We describe our experience with CE from a single centre in NZ.

Method

In this 2-year, retrospective, study of 122 consecutive patients, data was collected on multiple variables from the patient clinical, laboratory, and radiology records. Pillcam of Given Imaging Diagnostic System (Given Imaging Ltd, Yogneam, Israel) was used to image the small bowel. Descriptive statistics were used to analyse the data.

Results

Good preparation was noted in 69% of the cases. The most common indication for referral was obscure GI bleeding (70%). The overall diagnostic yield for relevant findings was 52%, with angioectasia as the most common specific finding (37%). The diagnostic yield in those with overt bleeds improved with inpatient status (74%). Incomplete examinations were noted in 12% and were significantly more common in the male gender. Preliminary imaging (barium, CT/MR) was noted to have a lower diagnostic yield. Enteroscopies were considered in 25% of the patients post CE procedure.

Conclusion

Apart from a lower diagnostic yield in patients with overt bleeds, our data is consistent with that reported in literature and support the role of CE as the minimally invasive gold standard investigation for small bowel imaging.

Author Information

Mohammad I Khan; Gastroenterologist, Tauranga Public Hospital, Tauranga; Megan Johnston; Medical Student, University of Otago, Dunedin; Robert Cunliffe; Gastroenterologist, Tauranga Public Hospital, Tauranga; Adrian Claydon; Gastroenterologist, Tauranga Public Hospital, Tauranga

Acknowledgements

Correspondence

Dr Mohammad Imran Khan, Gastroenterologist, Tauranga Public Hospital, Tauranga, New Zealand

Correspondence Email

imran.khan@bopdhb.govt.nz

Competing Interests

Nil.

Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature. [Article]. 2000 May;405 (6785):417.Waterman M, Eliakim R. Capsule enteroscopy of the small intestine. Abdom Imaging. [Review]. 2009 Jul;34(4):452-8.Lewis BS, Eisen GM, Friedman S. A pooled analysis to evaluate results of capsule endoscopy trials. Endoscopy. [Article]. 2005 Oct;37(10):960-5.Waterman M, Gralnek IM. Capsule endoscopy of the esophagus. J Clin Gastroenterol. [Review]. 2009 Aug;43 (7):605-12.Eliakim R, Fireman Z, Gralnek IM, et al. Evaluation of the PillCam Colon capsule in the detection of colonic pathology: results of the first multicenter, prospective, comparative study. Endoscopy. [Article]. 2006 Oct;38(10):963-70.Lewis B, Goldfarb N. The advent of capsule endoscopy - a not-so-futuristic approach to obscure gastrointestinal bleeding. Aliment Pharmacol Ther. [Review]. 2003 May;17(9):1085-96.Doherty GA, Moss AC, Cheifetz AS. Capsule endoscopy for small-bowel evaluation in Crohn's disease. Gastrointest Endosc. [Review]. 2011 Jul;74(1):167-75.Spada C, Pirozzi GA, Riccioni ME, et al. Capsule endoscopy in patients with chronic abdominal pain. Dig Liver Dis. [Article]. 2006 Sep;38(9):696-8.Shim KN, Kim YS, Kim KJ, et al. Abdominal pain accompanied by weight loss may increase the diagnostic yield of capsule endoscopy: A Korean multicenter study. Scand J Gastroenterol. [Article]. 2006 Aug;41(8):983-8.Lidums I, Cummins AG, Teo E. The Role of Capsule Endoscopy in Suspected Celiac Disease Patients with Positive Celiac Serology. Dig Dis Sci. [Article]. 2011 Feb;56(2):499-505.von Allmen D. Intestinal polyposis syndromes: progress in understanding and treatment. Curr Opin Pediatr. [Review]. 2006 Jun;18(3):316-20.Jurawan R, Taylor J, Brooker, J. Wireless Capsule Endoscopy (WCE): A single study experience of 82 WCE. Journ Gastroenterol & Hepatol. 2009,A 270 (Suppl.2).Leighton JA, Legnani P, Seidman EG. Role of capsule endoscopy in inflammatory bowel disease: Where we are and where we are going. Inflamm Bowel Dis. [Review]. 2007 Mar;13(3):331-7.Dionisio PM, Gurudu SR, Leighton JA, et al. capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohn's disease: a meta-analysis. Am J Gastroenterol. [Review]. 2010 Jun;105(6):1240-8.Rastogi A, Schoen RE, Slivka A. Diagnostic yield and clinical outcomes of capsule endoscopy. Gastrointest Endosc. [Article]. 2004 Dec;60(6):959-64.Tatar EL, Shen EH, Palance A, et al. Clinical utility of wireless capsule endoscopy - Experience with 200 cases. Journal of Clinical Gastroenterology 2006;40(2):140-144.Bresci G, Parisi G, Bertoni M, et al. The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use. J Gastroenterol. [Article]. 2005 Mar;40(3):256-9.Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: Report of 100 consecutive cases. Gastroenterology. [Article]. 2004 Mar;126(3):643-53.Apostolopoulos P, Liatsos C, Gralnek IM, et al. Evaluation of capsule endoscopy in active, mild-to-moderate, overt, obscure GI bleeding. Gastrointestinal Endoscopy 2007;66(6):1174-1181.Robinson CA, Jackson C, Condon D , et al. Impact of inpatient status and gender on small-bowel capsule endoscopy findings. Gastrointestinal Endoscopy 2011;74(5):1061-1066.Lee MM, Jacques A, Lam E, et al. Factors associated with incomplete small bowel capsule endoscopy studies. World Journal of Gastroenterology 2010;16(42):5329-5333.Hoog, CM, Bark LA, Arkani J, et al. Capsule retentions and incomplete capsule endoscopy examinations: an analysis of 2300 examinations. Gastroenterology Research and Practice. 2012;Vol 2012, (Article ID 518718)..Crook DW, Knuesel PR, Froehlich JM, et al. Comparison of magnetic resonance enterography and video capsule endoscopy in evaluating small bowel disease. Eur J Gastroenterol Hepatol. [Article]. 2009 Jan;21(1):54-65.Postgate A, Hyer W, Phillips R, et al. Feasibility of Video Capsule Endoscopy in the Management of Children With Peutz-Jeghers Syndrome: A Blinded Comparison With Barium Enterography for the Detection of Small Bowel Polyps. J Pediatr Gastroenterol Nutr. [Article]. 2009 Oct;49(4):417-23.Gisbert JP, McNicholl AG. Questions and answers on the role of faecal calprotectin as a biological marker in inflammatory bowel disease. Dig Liver Dis. [Review]. 2009 Jan;41(1):56-66.Konikoff MR, Denson LA. Role of fecal calprotectin as a biomarker of intestinal inflammation in inflammatory bowel disease. Inflamm Bowel Dis. [Review]. 2006 Jun;12(6):524-34.Schoepfer AM, Beglinger C, Straumann A, et al. Ulcerative Colitis: Correlation of the Rachmilewitz Endoscopic Activity Index with Fecal Calprotectin, Clinical Activity, C-reactive Protein, and Blood Leukocytes. Inflamm Bowel Dis. [Article]. 2009 Dec;15(12):1851-8.Tibble JA, Sigthorsson G, Foster R, et al. High prevalence of NSAID enteropathy as shown by a simple faecal test. Gut. [Article]. 1999 Sep;45(3):362-6.Pennazio, M., G. Eisen, et al. (2005). ICCE consensus for obscure gastrointestinal bleeding.\" Endoscopy 37(10): 1046-1050Van Turenhout ST, Jacobs M, van Weyenberg SJ, et al. Diagnostic Yield of Capsule Endoscopy in a Tertiary Hospital in Patients with Obscure Gastrointestinal Bleeding. J Gastrointest Liver Dis. [Article]. 2010 Jun;19(2):141-5.Girelli CM, Maiero S, Porta P, Cannizzaro R. Small Bowel Capsule Endoscopy Performance in Octogenarians: A Case-Control Study. J Gerontol Ser A-Biol Sci Med Sci. [Article]. 2011 Jan;66(1):68-73.Scaglione G, Russo F, et al. Age and video capsule endoscopy in obscure gastrointestinal bleeding: a prospective study on hospitalized patients. Digestive Diseases and Sciences 2011;56(4):1188-1193.Niv Y. Efficiency of bowel preparation for capsule endoscopy examination: A meta-analysis. World J Gastroenterol. [Editorial Material]. 2008 Mar;14(9):1313-7.Park SC, Keum B, Hyun JJ, et al. A novel cleansing score system for capsule endoscopy. World J Gastroenterol. [Article]. 2010 Feb;16(7):875-80.Barnett CB, Dipalma JA, Olden KW. Capsule endoscopy: impact on patient management. Gastroenterol & hepatol. 2007 2007;3(2):124-6.

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Capsule endoscopy (CE) was first approved as a diagnostic tool for small bowel imaging in year 2000 in the United States.1 At that time the small bowel was considered a particularly difficult area to examine and the imaging modalities used included sonography, computed tomography (CT), enterography (CT/MR), enterocylis and push enteroscopy. Apart from the potential for complications, these modalities have a low diagnostic yield.2Subsequent studies have now established CE as the gold standard for small bowel imaging.3The procedure is painless, does not require sedation, is easy to perform and for the first time enables exploration of the entire small bowel at high magnification. Oesophageal and colonic capsule endoscopies have also been recently introduced for imaging the upper and lower gastrointestinal (GI) tracts respectively.4,5The two main clinical areas where CE has made a significant impact are in the diagnostic workup of patients with obscure GI bleeding and those with suspected small bowel inflammation mainly due to early Crohns disease. The former include patients with overt or occult GI bleeding with normal upper and lower endoscopies.6 The latter include patients with chronic diarrhoea with a clinical and laboratory setting suggestive of small bowel inflammation/ulceration (high inflammatory markers and high faecal calprotectin levels) rather than irritable bowel syndrome.7The role of small bowel CE has also been explored in other clinical settings including non specific abdominal pain, unexplained weight loss, suspected celiac disease and for surveillance in patients with small bowel tumors.8-11In New Zealand (NZ) small bowel capsule endoscopy has been introduced in all tertiary and a few of the secondary centres. To date, no data has been published from these centres apart from an abstract publication in 2009 from Waikato Hospital.12 We present our 2-year experience with 122 consecutive patients from a single centre in New Zealand.Patients and Methods This is a single centre, retrospective study, of 122 consecutive patients referred for small bowel capsule endoscopy to our unit from December 2009 to December 2011. All patients had previously undergone diagnostic procedures including gastroscopy, colonoscopy and CT or MRI examinations. Each patient was given a study leaflet explaining the nature of the procedure and an informed consent was signed. Routine history and physical examination was not performed on the day of the procedure. All outpatients had a bowel preparation with 2 litres of polyethylene glycol and started on clear fluids from the afternoon before the procedure. Metoclopramide, in oral dosage of 10mg was routinely given before the study. Inpatient were not routinely given prokinetics or bowel lavage but were given at the discretion of the requesting gastroenterologist. Clear fluids were started 2 hours after the capsule ingestion and a light snack given at 4 hours. Normal dietary habits were resumed after 8 hours. The bowel preparation in the study was graded as good, fair, or poor depending upon the adequacy of the examination. Any light contamination impairing views was also recorded. A patency capsule was administered first before the study in patients with suspected small bowel strictures. A CE placement device was used to deliver the capsule in patients with swallowing difficulties and those with gastroparesis. Contraindications to the study included patients with known intestinal strictures and those presenting with clinical and radiological evidence of small bowel obstruction. Patients were grouped according to their main presentation. Patients with obscure GI bleeding were stratified into those with overt bleeding and those with occult bleeding, either with accompanying iron deficiency anaemia or a low ferritin/FOB positive stool test. Patients with chronic diarrhoea (including those with suspected Crohns disease) and those with chronic non specific abdominal pain were classed separately. All other presentations including weight loss, suspected GI malignancy and suspected celiac disease were grouped together in the Other category. All the studies were performed by our endoscopy nurses according to the current protocol of our unit. The Given Imaging Diagnostic System (Given Imaging Ltd, Yogneam, Israel) was used; it involves the pillcam capsule, a data recorder worn by the patient during the study, and a work-station used to process and analyse the images using the Rapid 6 Reader software. Each study was read independently by two of the three gastroenterologists with expertise in the procedure. The CE images of the oesophagus, stomach and the colon were also read. The results were discussed and a combined report was later written. Data for the study was collected from the patients clinical, laboratory and radiology records and the Rapid 6 Reader software. CE findings in the study were classed as: Relevant - if they accounted for the patients presentation, e.g. vascular ectasias in a patient with iron deficiency anaemia or fresh blood in the lumen in patients with overt bleeds; Significant - if they were not relevant to the clinical presentation but still important to be noted, e.g. ulcers, polyps or neoplasms; and Normal - this class included those with a normal study and also those with insignificant findings (e.g. venous lakes, prominent vessels, prominent mucosal folds, submucosal bulges, red spots etc). Cases with relevant/significant findings in the Upper GI tract or colon but missed on prior endoscopies were also recorded. If more than one lesion was found during a study, then only the most relevant lesion was counted. In our study ulcers and aphthous ulcers were counted together, separate from erosions and fresh blood in the lumen was counted as a relevant finding. The completion status of the study was classed as Complete - when the capsule reached the caecum and Incomplete when either the capsule did not leave the stomach or failed to reach the caecum. A plain abdominal X-ray was taken if the patient did not report passing out the capsule 5 days after ingestion. A comparative analysis of CE findings was made, both with the imaging studies (barium/CT or MR Enterography) done up to a year before the CE examination for the same indication and with the faecal (calprotectin) and plasma (CRP) inflammatory markers done prior to the CE study. Procedure-related complications and post CE procedures recommended by the reporting gastroenterologist were also noted. Results Table 1 shows the indications for referral according to the gender, age category and inpatient status of the examination. The status of bowel preparation in different indications is also noted. The most common indication for referral was obscure GI bleeding (70%, N=86) which was sub-classified into overt bleeding (n=33), iron deficiency anaemia (n=39) and those with no anaemia but low ferritin (n=14). Patients referred with predominant diarrhoea, for workup for suspected enteropathy (n=18) and patients with non-specific abdominal pain (n=10) were the other significant groups. Rare indications, including suspected celiac disease and studies in Peutz Jegher patients were grouped into the other category. Table 1. Summary statistics, acuity status and bowel preparation Variables Obscure GI bleed (N=86) Predominant diarrhoea Abdominal pain Other indications Overt Occult Anaemia Low ferritin (N=18) (N=10) (N=8) Gender Male Female 25 8 19 20 6 8 6 12 5 5 2 6 Age <40 years 40-75 years >75 years 2 17 14 4 26 9 0 12 2 3 10 5 8 2 0 2 5 1 Acuity Outpatients Inpatients 14 19 39 0 14 0 16 2 7 3 7 1 Preparation Good Fair Poor 21 11 1 29 9 1 9 5 0 14 4 0 6 4 0 5 2 1 In our study 69% of the studies had good preparation, 29% had fair preparation while the rest had poor preparation. Light contamination, causing suboptimal views was noted in five patients (4%). No relationship was noted between the quality of preparation and the indication for the procedure. Inpatient CE examination were carried out in 25 (20%) patients. Nineteen of them were for overt bleeds. The diagnostic yield improved with inpatient examination in only the sub-group with overt bleeds (up to 74%). In the non-GI bleed studies only one out of the six patients with inpatient study had relevant findings. Majority of the inpatient examinations were carried out in male patients (76%). This was because presentation with overt bleeds was significantly more common in males (70%). The overall diagnostic yield of CE studies for findings relevant to the clinical indication in our study was 52%. Relevant gastric and colonic findings, picked on CE examination but missed on prior endoscopy were 2% and 6% respectively. Table 2 shows the influence of gender, age, inpatient status and indication for referral on the diagnostic yield of the study. Highest yield was seen in patients referred for overt bleeds (66%) and lowest yield in those referred for non-specific abdominal pain (8%). The total diagnostic yield (small bowel, stomach and colon) of relevant/significant findings was more in inpatients (75%) and the elderly (80%) but was not affected by the gender of the patient. Table 2. Diagnostic yield by gender, age, acuity and indication Variables Relevant and significant findings Normal and insignificant findings Gender Males Females 41 34 22 25 Age category <40 years 40-75 years >75 years 7 43 25 12 29 6 Acuity Outpatients Inpatients 56 19 41 6 Indication Overt bleeds Anaemia Low ferritin Diarrhoea Abdominal pain Others 27 27 7 12 2 1 6 12 7 6 8 7 We only calculated the frequency of specific findings in those studies where the findings were relevant/significant to the indication for the study. If more than one finding was reported, then the most relevant/significant finding was counted. Overall angioectasias (36%) and ulcers/apthous ulcers (32%) were the most frequent specific findings (Figure 1). For specific indications, the most frequently reported specific finding in those with overt bleed was fresh blood in the lumen (38%), and angioectasia (35%), in iron deficiency was angioectasia (52%), and in those with predominant diarrhoea was ulcer (75%). Figure 1. Frequency of relevant/significant findings GAVE= Gastric Antral Vascular Ectasias. Barium and CT/MR studies of the small bowel were done in 19 cases (16%), mainly in those with indications other than suspected GI bleeds (Table 3). Findings were consistent with the CE findings in 12 cases (63%) and false negative in seven cases (37%). No false positive cases were reported. As shown in the Table 3 most studies were done for cases presenting with predominant diarrhoea, where both the concordance and the false negative rates were 50%. CRP and faecal calprotectin measurements were also recorded in the subgroup of patients presenting predominantly with diarrhoea and non-specific abdominal discomfort (data not illustrated). In those with predominant diarrhoea, faecal calprotectin was raised in all but one case (when measured) compared to CRP levels which were recorded as normal in 56% (9 out of 16 measured) of the cases. However, the faecal calprotectin levels correlated correctly with CE findings in only 64% of the cases. In five cases (35%) the faecal calprotectin was falsely elevated, that is, the levels were significantly raised but the CE examination was unremarkable. Table 3. Preliminary imaging Variables Obscure GI bleeds Predominant diarrhoea Abdominal pain Other indications Overt Occult Anaemia Low ferritin Imaging not done concordant false negatives false positives 32 0 1 0 36 3 0 0 14 0

Summary

Abstract

Aim

Small bowel capsule endoscopy (CE) has been introduced in New Zealand (NZ) in all of the tertiary and some secondary centres over the last few years. We describe our experience with CE from a single centre in NZ.

Method

In this 2-year, retrospective, study of 122 consecutive patients, data was collected on multiple variables from the patient clinical, laboratory, and radiology records. Pillcam of Given Imaging Diagnostic System (Given Imaging Ltd, Yogneam, Israel) was used to image the small bowel. Descriptive statistics were used to analyse the data.

Results

Good preparation was noted in 69% of the cases. The most common indication for referral was obscure GI bleeding (70%). The overall diagnostic yield for relevant findings was 52%, with angioectasia as the most common specific finding (37%). The diagnostic yield in those with overt bleeds improved with inpatient status (74%). Incomplete examinations were noted in 12% and were significantly more common in the male gender. Preliminary imaging (barium, CT/MR) was noted to have a lower diagnostic yield. Enteroscopies were considered in 25% of the patients post CE procedure.

Conclusion

Apart from a lower diagnostic yield in patients with overt bleeds, our data is consistent with that reported in literature and support the role of CE as the minimally invasive gold standard investigation for small bowel imaging.

Author Information

Mohammad I Khan; Gastroenterologist, Tauranga Public Hospital, Tauranga; Megan Johnston; Medical Student, University of Otago, Dunedin; Robert Cunliffe; Gastroenterologist, Tauranga Public Hospital, Tauranga; Adrian Claydon; Gastroenterologist, Tauranga Public Hospital, Tauranga

Acknowledgements

Correspondence

Dr Mohammad Imran Khan, Gastroenterologist, Tauranga Public Hospital, Tauranga, New Zealand

Correspondence Email

imran.khan@bopdhb.govt.nz

Competing Interests

Nil.

Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature. [Article]. 2000 May;405 (6785):417.Waterman M, Eliakim R. Capsule enteroscopy of the small intestine. Abdom Imaging. [Review]. 2009 Jul;34(4):452-8.Lewis BS, Eisen GM, Friedman S. A pooled analysis to evaluate results of capsule endoscopy trials. Endoscopy. [Article]. 2005 Oct;37(10):960-5.Waterman M, Gralnek IM. Capsule endoscopy of the esophagus. J Clin Gastroenterol. [Review]. 2009 Aug;43 (7):605-12.Eliakim R, Fireman Z, Gralnek IM, et al. Evaluation of the PillCam Colon capsule in the detection of colonic pathology: results of the first multicenter, prospective, comparative study. Endoscopy. [Article]. 2006 Oct;38(10):963-70.Lewis B, Goldfarb N. The advent of capsule endoscopy - a not-so-futuristic approach to obscure gastrointestinal bleeding. Aliment Pharmacol Ther. [Review]. 2003 May;17(9):1085-96.Doherty GA, Moss AC, Cheifetz AS. Capsule endoscopy for small-bowel evaluation in Crohn's disease. Gastrointest Endosc. [Review]. 2011 Jul;74(1):167-75.Spada C, Pirozzi GA, Riccioni ME, et al. Capsule endoscopy in patients with chronic abdominal pain. Dig Liver Dis. [Article]. 2006 Sep;38(9):696-8.Shim KN, Kim YS, Kim KJ, et al. Abdominal pain accompanied by weight loss may increase the diagnostic yield of capsule endoscopy: A Korean multicenter study. Scand J Gastroenterol. [Article]. 2006 Aug;41(8):983-8.Lidums I, Cummins AG, Teo E. The Role of Capsule Endoscopy in Suspected Celiac Disease Patients with Positive Celiac Serology. Dig Dis Sci. [Article]. 2011 Feb;56(2):499-505.von Allmen D. Intestinal polyposis syndromes: progress in understanding and treatment. Curr Opin Pediatr. [Review]. 2006 Jun;18(3):316-20.Jurawan R, Taylor J, Brooker, J. Wireless Capsule Endoscopy (WCE): A single study experience of 82 WCE. Journ Gastroenterol & Hepatol. 2009,A 270 (Suppl.2).Leighton JA, Legnani P, Seidman EG. Role of capsule endoscopy in inflammatory bowel disease: Where we are and where we are going. Inflamm Bowel Dis. [Review]. 2007 Mar;13(3):331-7.Dionisio PM, Gurudu SR, Leighton JA, et al. capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohn's disease: a meta-analysis. Am J Gastroenterol. [Review]. 2010 Jun;105(6):1240-8.Rastogi A, Schoen RE, Slivka A. Diagnostic yield and clinical outcomes of capsule endoscopy. Gastrointest Endosc. [Article]. 2004 Dec;60(6):959-64.Tatar EL, Shen EH, Palance A, et al. Clinical utility of wireless capsule endoscopy - Experience with 200 cases. Journal of Clinical Gastroenterology 2006;40(2):140-144.Bresci G, Parisi G, Bertoni M, et al. The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use. J Gastroenterol. [Article]. 2005 Mar;40(3):256-9.Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: Report of 100 consecutive cases. Gastroenterology. [Article]. 2004 Mar;126(3):643-53.Apostolopoulos P, Liatsos C, Gralnek IM, et al. Evaluation of capsule endoscopy in active, mild-to-moderate, overt, obscure GI bleeding. Gastrointestinal Endoscopy 2007;66(6):1174-1181.Robinson CA, Jackson C, Condon D , et al. Impact of inpatient status and gender on small-bowel capsule endoscopy findings. Gastrointestinal Endoscopy 2011;74(5):1061-1066.Lee MM, Jacques A, Lam E, et al. Factors associated with incomplete small bowel capsule endoscopy studies. World Journal of Gastroenterology 2010;16(42):5329-5333.Hoog, CM, Bark LA, Arkani J, et al. Capsule retentions and incomplete capsule endoscopy examinations: an analysis of 2300 examinations. Gastroenterology Research and Practice. 2012;Vol 2012, (Article ID 518718)..Crook DW, Knuesel PR, Froehlich JM, et al. Comparison of magnetic resonance enterography and video capsule endoscopy in evaluating small bowel disease. Eur J Gastroenterol Hepatol. [Article]. 2009 Jan;21(1):54-65.Postgate A, Hyer W, Phillips R, et al. Feasibility of Video Capsule Endoscopy in the Management of Children With Peutz-Jeghers Syndrome: A Blinded Comparison With Barium Enterography for the Detection of Small Bowel Polyps. J Pediatr Gastroenterol Nutr. [Article]. 2009 Oct;49(4):417-23.Gisbert JP, McNicholl AG. Questions and answers on the role of faecal calprotectin as a biological marker in inflammatory bowel disease. Dig Liver Dis. [Review]. 2009 Jan;41(1):56-66.Konikoff MR, Denson LA. Role of fecal calprotectin as a biomarker of intestinal inflammation in inflammatory bowel disease. Inflamm Bowel Dis. [Review]. 2006 Jun;12(6):524-34.Schoepfer AM, Beglinger C, Straumann A, et al. Ulcerative Colitis: Correlation of the Rachmilewitz Endoscopic Activity Index with Fecal Calprotectin, Clinical Activity, C-reactive Protein, and Blood Leukocytes. Inflamm Bowel Dis. [Article]. 2009 Dec;15(12):1851-8.Tibble JA, Sigthorsson G, Foster R, et al. High prevalence of NSAID enteropathy as shown by a simple faecal test. Gut. [Article]. 1999 Sep;45(3):362-6.Pennazio, M., G. Eisen, et al. (2005). ICCE consensus for obscure gastrointestinal bleeding.\" Endoscopy 37(10): 1046-1050Van Turenhout ST, Jacobs M, van Weyenberg SJ, et al. Diagnostic Yield of Capsule Endoscopy in a Tertiary Hospital in Patients with Obscure Gastrointestinal Bleeding. J Gastrointest Liver Dis. [Article]. 2010 Jun;19(2):141-5.Girelli CM, Maiero S, Porta P, Cannizzaro R. Small Bowel Capsule Endoscopy Performance in Octogenarians: A Case-Control Study. J Gerontol Ser A-Biol Sci Med Sci. [Article]. 2011 Jan;66(1):68-73.Scaglione G, Russo F, et al. Age and video capsule endoscopy in obscure gastrointestinal bleeding: a prospective study on hospitalized patients. Digestive Diseases and Sciences 2011;56(4):1188-1193.Niv Y. Efficiency of bowel preparation for capsule endoscopy examination: A meta-analysis. World J Gastroenterol. [Editorial Material]. 2008 Mar;14(9):1313-7.Park SC, Keum B, Hyun JJ, et al. A novel cleansing score system for capsule endoscopy. World J Gastroenterol. [Article]. 2010 Feb;16(7):875-80.Barnett CB, Dipalma JA, Olden KW. Capsule endoscopy: impact on patient management. Gastroenterol & hepatol. 2007 2007;3(2):124-6.

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Capsule endoscopy (CE) was first approved as a diagnostic tool for small bowel imaging in year 2000 in the United States.1 At that time the small bowel was considered a particularly difficult area to examine and the imaging modalities used included sonography, computed tomography (CT), enterography (CT/MR), enterocylis and push enteroscopy. Apart from the potential for complications, these modalities have a low diagnostic yield.2Subsequent studies have now established CE as the gold standard for small bowel imaging.3The procedure is painless, does not require sedation, is easy to perform and for the first time enables exploration of the entire small bowel at high magnification. Oesophageal and colonic capsule endoscopies have also been recently introduced for imaging the upper and lower gastrointestinal (GI) tracts respectively.4,5The two main clinical areas where CE has made a significant impact are in the diagnostic workup of patients with obscure GI bleeding and those with suspected small bowel inflammation mainly due to early Crohns disease. The former include patients with overt or occult GI bleeding with normal upper and lower endoscopies.6 The latter include patients with chronic diarrhoea with a clinical and laboratory setting suggestive of small bowel inflammation/ulceration (high inflammatory markers and high faecal calprotectin levels) rather than irritable bowel syndrome.7The role of small bowel CE has also been explored in other clinical settings including non specific abdominal pain, unexplained weight loss, suspected celiac disease and for surveillance in patients with small bowel tumors.8-11In New Zealand (NZ) small bowel capsule endoscopy has been introduced in all tertiary and a few of the secondary centres. To date, no data has been published from these centres apart from an abstract publication in 2009 from Waikato Hospital.12 We present our 2-year experience with 122 consecutive patients from a single centre in New Zealand.Patients and Methods This is a single centre, retrospective study, of 122 consecutive patients referred for small bowel capsule endoscopy to our unit from December 2009 to December 2011. All patients had previously undergone diagnostic procedures including gastroscopy, colonoscopy and CT or MRI examinations. Each patient was given a study leaflet explaining the nature of the procedure and an informed consent was signed. Routine history and physical examination was not performed on the day of the procedure. All outpatients had a bowel preparation with 2 litres of polyethylene glycol and started on clear fluids from the afternoon before the procedure. Metoclopramide, in oral dosage of 10mg was routinely given before the study. Inpatient were not routinely given prokinetics or bowel lavage but were given at the discretion of the requesting gastroenterologist. Clear fluids were started 2 hours after the capsule ingestion and a light snack given at 4 hours. Normal dietary habits were resumed after 8 hours. The bowel preparation in the study was graded as good, fair, or poor depending upon the adequacy of the examination. Any light contamination impairing views was also recorded. A patency capsule was administered first before the study in patients with suspected small bowel strictures. A CE placement device was used to deliver the capsule in patients with swallowing difficulties and those with gastroparesis. Contraindications to the study included patients with known intestinal strictures and those presenting with clinical and radiological evidence of small bowel obstruction. Patients were grouped according to their main presentation. Patients with obscure GI bleeding were stratified into those with overt bleeding and those with occult bleeding, either with accompanying iron deficiency anaemia or a low ferritin/FOB positive stool test. Patients with chronic diarrhoea (including those with suspected Crohns disease) and those with chronic non specific abdominal pain were classed separately. All other presentations including weight loss, suspected GI malignancy and suspected celiac disease were grouped together in the Other category. All the studies were performed by our endoscopy nurses according to the current protocol of our unit. The Given Imaging Diagnostic System (Given Imaging Ltd, Yogneam, Israel) was used; it involves the pillcam capsule, a data recorder worn by the patient during the study, and a work-station used to process and analyse the images using the Rapid 6 Reader software. Each study was read independently by two of the three gastroenterologists with expertise in the procedure. The CE images of the oesophagus, stomach and the colon were also read. The results were discussed and a combined report was later written. Data for the study was collected from the patients clinical, laboratory and radiology records and the Rapid 6 Reader software. CE findings in the study were classed as: Relevant - if they accounted for the patients presentation, e.g. vascular ectasias in a patient with iron deficiency anaemia or fresh blood in the lumen in patients with overt bleeds; Significant - if they were not relevant to the clinical presentation but still important to be noted, e.g. ulcers, polyps or neoplasms; and Normal - this class included those with a normal study and also those with insignificant findings (e.g. venous lakes, prominent vessels, prominent mucosal folds, submucosal bulges, red spots etc). Cases with relevant/significant findings in the Upper GI tract or colon but missed on prior endoscopies were also recorded. If more than one lesion was found during a study, then only the most relevant lesion was counted. In our study ulcers and aphthous ulcers were counted together, separate from erosions and fresh blood in the lumen was counted as a relevant finding. The completion status of the study was classed as Complete - when the capsule reached the caecum and Incomplete when either the capsule did not leave the stomach or failed to reach the caecum. A plain abdominal X-ray was taken if the patient did not report passing out the capsule 5 days after ingestion. A comparative analysis of CE findings was made, both with the imaging studies (barium/CT or MR Enterography) done up to a year before the CE examination for the same indication and with the faecal (calprotectin) and plasma (CRP) inflammatory markers done prior to the CE study. Procedure-related complications and post CE procedures recommended by the reporting gastroenterologist were also noted. Results Table 1 shows the indications for referral according to the gender, age category and inpatient status of the examination. The status of bowel preparation in different indications is also noted. The most common indication for referral was obscure GI bleeding (70%, N=86) which was sub-classified into overt bleeding (n=33), iron deficiency anaemia (n=39) and those with no anaemia but low ferritin (n=14). Patients referred with predominant diarrhoea, for workup for suspected enteropathy (n=18) and patients with non-specific abdominal pain (n=10) were the other significant groups. Rare indications, including suspected celiac disease and studies in Peutz Jegher patients were grouped into the other category. Table 1. Summary statistics, acuity status and bowel preparation Variables Obscure GI bleed (N=86) Predominant diarrhoea Abdominal pain Other indications Overt Occult Anaemia Low ferritin (N=18) (N=10) (N=8) Gender Male Female 25 8 19 20 6 8 6 12 5 5 2 6 Age <40 years 40-75 years >75 years 2 17 14 4 26 9 0 12 2 3 10 5 8 2 0 2 5 1 Acuity Outpatients Inpatients 14 19 39 0 14 0 16 2 7 3 7 1 Preparation Good Fair Poor 21 11 1 29 9 1 9 5 0 14 4 0 6 4 0 5 2 1 In our study 69% of the studies had good preparation, 29% had fair preparation while the rest had poor preparation. Light contamination, causing suboptimal views was noted in five patients (4%). No relationship was noted between the quality of preparation and the indication for the procedure. Inpatient CE examination were carried out in 25 (20%) patients. Nineteen of them were for overt bleeds. The diagnostic yield improved with inpatient examination in only the sub-group with overt bleeds (up to 74%). In the non-GI bleed studies only one out of the six patients with inpatient study had relevant findings. Majority of the inpatient examinations were carried out in male patients (76%). This was because presentation with overt bleeds was significantly more common in males (70%). The overall diagnostic yield of CE studies for findings relevant to the clinical indication in our study was 52%. Relevant gastric and colonic findings, picked on CE examination but missed on prior endoscopy were 2% and 6% respectively. Table 2 shows the influence of gender, age, inpatient status and indication for referral on the diagnostic yield of the study. Highest yield was seen in patients referred for overt bleeds (66%) and lowest yield in those referred for non-specific abdominal pain (8%). The total diagnostic yield (small bowel, stomach and colon) of relevant/significant findings was more in inpatients (75%) and the elderly (80%) but was not affected by the gender of the patient. Table 2. Diagnostic yield by gender, age, acuity and indication Variables Relevant and significant findings Normal and insignificant findings Gender Males Females 41 34 22 25 Age category <40 years 40-75 years >75 years 7 43 25 12 29 6 Acuity Outpatients Inpatients 56 19 41 6 Indication Overt bleeds Anaemia Low ferritin Diarrhoea Abdominal pain Others 27 27 7 12 2 1 6 12 7 6 8 7 We only calculated the frequency of specific findings in those studies where the findings were relevant/significant to the indication for the study. If more than one finding was reported, then the most relevant/significant finding was counted. Overall angioectasias (36%) and ulcers/apthous ulcers (32%) were the most frequent specific findings (Figure 1). For specific indications, the most frequently reported specific finding in those with overt bleed was fresh blood in the lumen (38%), and angioectasia (35%), in iron deficiency was angioectasia (52%), and in those with predominant diarrhoea was ulcer (75%). Figure 1. Frequency of relevant/significant findings GAVE= Gastric Antral Vascular Ectasias. Barium and CT/MR studies of the small bowel were done in 19 cases (16%), mainly in those with indications other than suspected GI bleeds (Table 3). Findings were consistent with the CE findings in 12 cases (63%) and false negative in seven cases (37%). No false positive cases were reported. As shown in the Table 3 most studies were done for cases presenting with predominant diarrhoea, where both the concordance and the false negative rates were 50%. CRP and faecal calprotectin measurements were also recorded in the subgroup of patients presenting predominantly with diarrhoea and non-specific abdominal discomfort (data not illustrated). In those with predominant diarrhoea, faecal calprotectin was raised in all but one case (when measured) compared to CRP levels which were recorded as normal in 56% (9 out of 16 measured) of the cases. However, the faecal calprotectin levels correlated correctly with CE findings in only 64% of the cases. In five cases (35%) the faecal calprotectin was falsely elevated, that is, the levels were significantly raised but the CE examination was unremarkable. Table 3. Preliminary imaging Variables Obscure GI bleeds Predominant diarrhoea Abdominal pain Other indications Overt Occult Anaemia Low ferritin Imaging not done concordant false negatives false positives 32 0 1 0 36 3 0 0 14 0

Summary

Abstract

Aim

Small bowel capsule endoscopy (CE) has been introduced in New Zealand (NZ) in all of the tertiary and some secondary centres over the last few years. We describe our experience with CE from a single centre in NZ.

Method

In this 2-year, retrospective, study of 122 consecutive patients, data was collected on multiple variables from the patient clinical, laboratory, and radiology records. Pillcam of Given Imaging Diagnostic System (Given Imaging Ltd, Yogneam, Israel) was used to image the small bowel. Descriptive statistics were used to analyse the data.

Results

Good preparation was noted in 69% of the cases. The most common indication for referral was obscure GI bleeding (70%). The overall diagnostic yield for relevant findings was 52%, with angioectasia as the most common specific finding (37%). The diagnostic yield in those with overt bleeds improved with inpatient status (74%). Incomplete examinations were noted in 12% and were significantly more common in the male gender. Preliminary imaging (barium, CT/MR) was noted to have a lower diagnostic yield. Enteroscopies were considered in 25% of the patients post CE procedure.

Conclusion

Apart from a lower diagnostic yield in patients with overt bleeds, our data is consistent with that reported in literature and support the role of CE as the minimally invasive gold standard investigation for small bowel imaging.

Author Information

Mohammad I Khan; Gastroenterologist, Tauranga Public Hospital, Tauranga; Megan Johnston; Medical Student, University of Otago, Dunedin; Robert Cunliffe; Gastroenterologist, Tauranga Public Hospital, Tauranga; Adrian Claydon; Gastroenterologist, Tauranga Public Hospital, Tauranga

Acknowledgements

Correspondence

Dr Mohammad Imran Khan, Gastroenterologist, Tauranga Public Hospital, Tauranga, New Zealand

Correspondence Email

imran.khan@bopdhb.govt.nz

Competing Interests

Nil.

Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature. [Article]. 2000 May;405 (6785):417.Waterman M, Eliakim R. Capsule enteroscopy of the small intestine. Abdom Imaging. [Review]. 2009 Jul;34(4):452-8.Lewis BS, Eisen GM, Friedman S. A pooled analysis to evaluate results of capsule endoscopy trials. Endoscopy. [Article]. 2005 Oct;37(10):960-5.Waterman M, Gralnek IM. Capsule endoscopy of the esophagus. J Clin Gastroenterol. [Review]. 2009 Aug;43 (7):605-12.Eliakim R, Fireman Z, Gralnek IM, et al. Evaluation of the PillCam Colon capsule in the detection of colonic pathology: results of the first multicenter, prospective, comparative study. Endoscopy. [Article]. 2006 Oct;38(10):963-70.Lewis B, Goldfarb N. The advent of capsule endoscopy - a not-so-futuristic approach to obscure gastrointestinal bleeding. Aliment Pharmacol Ther. [Review]. 2003 May;17(9):1085-96.Doherty GA, Moss AC, Cheifetz AS. Capsule endoscopy for small-bowel evaluation in Crohn's disease. Gastrointest Endosc. [Review]. 2011 Jul;74(1):167-75.Spada C, Pirozzi GA, Riccioni ME, et al. Capsule endoscopy in patients with chronic abdominal pain. Dig Liver Dis. [Article]. 2006 Sep;38(9):696-8.Shim KN, Kim YS, Kim KJ, et al. Abdominal pain accompanied by weight loss may increase the diagnostic yield of capsule endoscopy: A Korean multicenter study. Scand J Gastroenterol. [Article]. 2006 Aug;41(8):983-8.Lidums I, Cummins AG, Teo E. The Role of Capsule Endoscopy in Suspected Celiac Disease Patients with Positive Celiac Serology. Dig Dis Sci. [Article]. 2011 Feb;56(2):499-505.von Allmen D. Intestinal polyposis syndromes: progress in understanding and treatment. Curr Opin Pediatr. [Review]. 2006 Jun;18(3):316-20.Jurawan R, Taylor J, Brooker, J. Wireless Capsule Endoscopy (WCE): A single study experience of 82 WCE. Journ Gastroenterol & Hepatol. 2009,A 270 (Suppl.2).Leighton JA, Legnani P, Seidman EG. Role of capsule endoscopy in inflammatory bowel disease: Where we are and where we are going. Inflamm Bowel Dis. [Review]. 2007 Mar;13(3):331-7.Dionisio PM, Gurudu SR, Leighton JA, et al. capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohn's disease: a meta-analysis. Am J Gastroenterol. [Review]. 2010 Jun;105(6):1240-8.Rastogi A, Schoen RE, Slivka A. Diagnostic yield and clinical outcomes of capsule endoscopy. Gastrointest Endosc. [Article]. 2004 Dec;60(6):959-64.Tatar EL, Shen EH, Palance A, et al. Clinical utility of wireless capsule endoscopy - Experience with 200 cases. Journal of Clinical Gastroenterology 2006;40(2):140-144.Bresci G, Parisi G, Bertoni M, et al. The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use. J Gastroenterol. [Article]. 2005 Mar;40(3):256-9.Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: Report of 100 consecutive cases. Gastroenterology. [Article]. 2004 Mar;126(3):643-53.Apostolopoulos P, Liatsos C, Gralnek IM, et al. Evaluation of capsule endoscopy in active, mild-to-moderate, overt, obscure GI bleeding. Gastrointestinal Endoscopy 2007;66(6):1174-1181.Robinson CA, Jackson C, Condon D , et al. Impact of inpatient status and gender on small-bowel capsule endoscopy findings. Gastrointestinal Endoscopy 2011;74(5):1061-1066.Lee MM, Jacques A, Lam E, et al. Factors associated with incomplete small bowel capsule endoscopy studies. World Journal of Gastroenterology 2010;16(42):5329-5333.Hoog, CM, Bark LA, Arkani J, et al. Capsule retentions and incomplete capsule endoscopy examinations: an analysis of 2300 examinations. Gastroenterology Research and Practice. 2012;Vol 2012, (Article ID 518718)..Crook DW, Knuesel PR, Froehlich JM, et al. Comparison of magnetic resonance enterography and video capsule endoscopy in evaluating small bowel disease. Eur J Gastroenterol Hepatol. [Article]. 2009 Jan;21(1):54-65.Postgate A, Hyer W, Phillips R, et al. Feasibility of Video Capsule Endoscopy in the Management of Children With Peutz-Jeghers Syndrome: A Blinded Comparison With Barium Enterography for the Detection of Small Bowel Polyps. J Pediatr Gastroenterol Nutr. [Article]. 2009 Oct;49(4):417-23.Gisbert JP, McNicholl AG. Questions and answers on the role of faecal calprotectin as a biological marker in inflammatory bowel disease. Dig Liver Dis. [Review]. 2009 Jan;41(1):56-66.Konikoff MR, Denson LA. Role of fecal calprotectin as a biomarker of intestinal inflammation in inflammatory bowel disease. Inflamm Bowel Dis. [Review]. 2006 Jun;12(6):524-34.Schoepfer AM, Beglinger C, Straumann A, et al. Ulcerative Colitis: Correlation of the Rachmilewitz Endoscopic Activity Index with Fecal Calprotectin, Clinical Activity, C-reactive Protein, and Blood Leukocytes. Inflamm Bowel Dis. [Article]. 2009 Dec;15(12):1851-8.Tibble JA, Sigthorsson G, Foster R, et al. High prevalence of NSAID enteropathy as shown by a simple faecal test. Gut. [Article]. 1999 Sep;45(3):362-6.Pennazio, M., G. Eisen, et al. (2005). ICCE consensus for obscure gastrointestinal bleeding.\" Endoscopy 37(10): 1046-1050Van Turenhout ST, Jacobs M, van Weyenberg SJ, et al. Diagnostic Yield of Capsule Endoscopy in a Tertiary Hospital in Patients with Obscure Gastrointestinal Bleeding. J Gastrointest Liver Dis. [Article]. 2010 Jun;19(2):141-5.Girelli CM, Maiero S, Porta P, Cannizzaro R. Small Bowel Capsule Endoscopy Performance in Octogenarians: A Case-Control Study. J Gerontol Ser A-Biol Sci Med Sci. [Article]. 2011 Jan;66(1):68-73.Scaglione G, Russo F, et al. Age and video capsule endoscopy in obscure gastrointestinal bleeding: a prospective study on hospitalized patients. Digestive Diseases and Sciences 2011;56(4):1188-1193.Niv Y. Efficiency of bowel preparation for capsule endoscopy examination: A meta-analysis. World J Gastroenterol. [Editorial Material]. 2008 Mar;14(9):1313-7.Park SC, Keum B, Hyun JJ, et al. A novel cleansing score system for capsule endoscopy. World J Gastroenterol. [Article]. 2010 Feb;16(7):875-80.Barnett CB, Dipalma JA, Olden KW. Capsule endoscopy: impact on patient management. Gastroenterol & hepatol. 2007 2007;3(2):124-6.

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