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