Wireless Capsule EndoscopyWireless Capsule Endoscopy

Eric Goldberg, M.D.Assistant Professor of Medicine

University of Maryland Medical CenterApril 8th, 2006

Case PresentationCase Presentation

SN is a 74 year old male with coronary artery disease, and chronically anticoagulated with coumadin for a artifical aortic valve, who presented 6 months prior to admission with melena and a hematocrit of 22%.

Upper endoscopy and colonoscopy were normal at that time. He was transfused, started on iron therapy and discharged home.

He was readmitted 2 months later with similar symptoms and a hematocrit of 18%. Repeat EGD and colonoscopy were again normal. An enteroscopy was performed to the proximal jejunum and was normal. He was again transfused, and discharged home.

Case PresentationCase Presentation

SN was readmitted again, 1 month prior to admission. EGD: normal.Small bowel follow through exam: normal. Tagged RBC scan: normal. Angiogram: Interventional radiology declinedIntra-operative enteroscopy. Surgery declined: Risks> Benefits

The patient was admitted a fourth time. He had received a total of 18 units of red blood cells over the preceding 6 months.

S.N. S.N.

Diagnosis: Bleeding AVM in Mid Jejunum

Enteroscopy: Bleeding in Mid-Jejunum

AVM in Mid Jejunum

AVM Post- Argon Plasma Coagulation

Follow UpFollow Up

SN has remained transfusion free for 12 months. He no longer takes iron and continues his coumadin therapy for his artificial aortic valve.

PatientPatient• XX is a 32 year old female with a history of Crohn’s

disease for ten years. Eight years ago, she underwent a terminal ileal resection with an ileo-transverse colon anastomosis.

• For the past 6 months, she was experiencing 4-6 loose stools per day and mid abdominal pain. She denied obstructive symptoms such as nausea, vomiting or obstipation.

• She was being treated with pentasa 3 grams/d and enterocort

• Laboratory evaluation was significant for an ESR of 55• A SBFT was normal• A colonoscopy was normal to the terminal ileum

Case PresentationCase Presentation

TR is a 69 year old male with recurrent melena. The patient initially presented 12 months earlier with melena and a HCT of 18%. An EGD and colonoscopy were normal. A small bowel follow through examination was negative. The patient was transfused, started on iron therapy and discharged.

He presented this admission with symptomatic anemia (HCT 14%) and OB+ stool. A repeat colonoscopy was negative. An enteroscopy was normal 30cm past the ligament of Treitz.

A capsule endoscopy was ordered…

Small Bowel Follow ThroughSmall Bowel Follow Through

Evaluation of the Small IntestineEvaluation of the Small Intestine

Push Enteroscopy 2.5meter long push enteroscopy Sonde and rope-way enteroscopy Angiography Red cell scans Intra-operative enteroscopy Double Balloon Enteroscopy

HistoryHistory

• Early 1980’s: Dr Gavriel Iddan, an Israeli mechanical engineer began working on electro-optical imaging devices for missiles.

• 1981: Dr Iddan goes on sabbatical in Boston- meets Dr Eitan Scapa, a gastroenterologist.

• The idea of developing a miniature missile that could pass through the GI tract and record images was born.

• 1994: Dr Paul Swain presents the possibility of wireless capsule endoscopy in an invited talk entitled Microwaves in Gastroenterology at the LA World Congress of Gastroenterology

HistoryHistory

• 1995-1996: Dr Swain develops several prototype wireless capsule endoscopy systems

• 1996: First live transmission from a pig• 1997: US patent• 1998: New start-up company: GIVEN imaging:

GastroIntestinal Video ENdoscopy• 2000: Animal trials presented at DDW• August, 2001: FDA approval• 2004: Esophageal Capsule Endoscopy• Future…

The CapsuleThe Capsule

• Diameter 11mm: Length 26mm• Optical dome: Intestinal illumination

by white light emitting diodes (LED’s)• Lens• Complementary metal-oxide silicone

imager (color camera chip)• Transmitter• Two batteries (silver oxide)

Features of the CapsuleFeatures of the Capsule

• Capsule takes two images per second• On average, 50,000 images are obtained during an

8 hour exam• Magnification: 8x• Capsule coating: non-adherant• Disposable

““Physiologic Endoscopy”Physiologic Endoscopy”

Bowel is visualized in its normal state No “scope trauma” Air insufflation not a factor

Exam can be performed on anticoagulation

GE Junction Duodenum

Jejunum Ileocecal Valve

Phlebectasia AVM

Lymphangectasia Bleeding Lesion

Lymphoma GIST

Polypoid Mass Polyp

NSAID stricture Radiation Enteritis

Sprue Villous Drop Out

PerformancePerformance1. Overnight 12 hour fast 2. Sensors placed on patient3. Patient wears a belt that contains a data recorder. 4. Patient ingests capsule around 8am5. Patient may have clears two hours after

ingestion6. Patient may have a light lunch 4 hours after

ingestion7. Avoid other patients who ingested a capsule. 8. Patient returns 7-8 hours later

Average Transit TimesAverage Transit Times

• Stomach: One hour

• Small Intestine: 4 hours

• Capsule Passage: 2-3 days

ComplicationsComplications

• Retention of capsule: 1-5%

• Bowel obstruction: .5 %

• Aspiration: Rare

ContraindicationsContraindicationsAbsolute:• Suspected small intestinal obstruction• Pacemakers/AICD’s. • Pregnancy

Relative:• Motility disturbances: Gastroparesis/Achalasia• Small bowel diverticulosis• Poor surgical candidates

Informed ConsentInformed Consent

• WCE does not replace examination of the stomach or colon

• Risk includes bowel obstruction that may require surgery

• No MRI’s until capsule has passed• May not visualize the entire small bowel

Reading the StudyReading the Study

• Reading times can vary from 20 minutes to 2 hours

• Can read up to 25 frames/sec in single frame mode. I recommend 12-15 frames/second

• Gadgets to speed reading times• Red finding software• Double/Quadruple frame imaging• Quick view

Capsule Endoscopy: Changing Capsule Endoscopy: Changing the Practice of Gastroenterologythe Practice of Gastroenterology

• Obscure gastrointestinal bleeding• Evaluation of extent of small intestinal disorders such as

Crohn’s disease or Celiac sprue• Abnormal small intestinal imaging• Surveillance of polyposis syndromes involving small

intestine