How to Slip the Capsule Down a Narrow Throat: Reply to Tóth et al.

In the space of only 3 years since its introduction, video capsule endoscopy (CE) of the small bowel has rapidly emerged as a novel, noninvasive imaging method for detecting previously undiagnosed small-bowel diseases such as obscure bleeding sources, polyps, and regional Crohn’s disease. However, the potential role for capsule endoscopy in the management of such diseases is still being clarified. A number of peer-reviewed studies [1] [2] [3] [4] [5] [6] have now appeared that compare CE with previous standard methods such as radiographic studies and push enteroscopy, and this may finally allow scientifically based use of this quite expensive diagnostic method. All of the studies so far published show that with regard to its diagnostic capacities, capsule endoscopy is better than push enteroscopy and better than standard radiographic examinations for detecting lesions located along the entire length of the small bowel. However, the method is also providing new insights into what happens in the small bowel in physiological conditions [6] and indicating which findings are clearly pathological in nature [1] [2] [3] [4] [7].

Since CE is relatively easy for gastroenterologists to perform, and since most studies support the widespread use of the procedure in the diagnostic algorithm of small-bowel examinations, it is not surprising that the limitations of the present technique are becoming more important in the clinical setting. While the problem of small-bowel obstruction and capsule retention can be minimized by careful history-taking and targeted examinations [7], other propulsion problems with the capsule - such as gastroparesis, decreased small-bowel transit, and esophageal motor abnormalities - require special attention in selected patients. In particular, functional motor problems in the intestine are not often anticipated before CE and can be difficult to assess. Other obstacles, such as esophageal strictures or swallowing difficulties, can be easily suspected by careful history-taking (to identify dysphagia, for example), which is mandatory before any CE procedure is performed. In patients with swallowing disorders, which are quite common in the geriatric setting, inadvertent passage of the capsule into the trachea or bronchi can be hazardous and must therefore be strictly avoided. Recently, techniques of endoscopically assisted video capsule endoscopy have been developed [5] [8], which are safe and facilitate capsule transport in patients with functional gastric outlet obstruction and other motor abnormalities. Our own experience, including a number of patients with intestinal motor disorders, strongly suggests that in all cases in which there is any doubt regarding passage of the capsule, CE should only be carried out with endoscopic assistance.

We therefore appreciate the case report by Tóth et al. [9] describing successful endoscopy-assisted capsule transport into the duodenum by using an overtube and net to pass the capsule through the throat in an elderly patient with swallowing problems and severe iron deficiency. This technique allowed the authors to start successful capsule imaging of the bleeding source in the small bowel [9], which later allowed targeted treatment with argon plasma coagulation delivered via a push enteroscope after the bleeding source had been located by CE. As in our study, the combination of the digital recording capsule with a conventional scope was safe and helpful.

This shows that CE is a complementary technique that can aid classical endoscopy by extending its reach, as has been shown in several other patients [5] [8]. Of course, the cost of CE and of additional instruments such as a Roth net, overtube, polypectomy snare, or Dormia basket must be carefully weighed up against the clinical impact of the CE findings in each individual case. If the indication is clear and treatment implications such as argon plasma coagulation or surgical therapy are likely to be drawn from the CE findings, we agree with the authors that endoscopy-assisted CE is a sophisticated technique for rapidly establishing a clear diagnosis in small-bowel disease.

References

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• 2 Ell C, Remke S, May A. et al . The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding.  Endoscopy. 2002;  34 685-689
• 3 Saurin J C, Delvaux M, Gaudin J L. et al . Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push-enteroscopy.  Endoscopy. 2003;  35 576-584
• 4 Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding.  Gut. 2003;  52 1122-1126
• 5 Hollerbach S, Kraus K, Willert J. et al . Endoscopically assisted video capsule endoscopy of the small bowel in patients with functional outlet obstruction.  Endoscopy. 2003;  35 226-229
• 6 Goldstein J, Eisen G, Lewis B. et al . Abnormal small bowel findings are common in healthy subjects screened for a multi-center, double blind, randomized, placebo-controlled trial using capsule endoscopy [abstract].  Gastroenterology. 2003;  124 (Suppl 1) 284
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• 9 Tóth E, Fork F T, Almqvist P, Thorlacius H. Endoscopy-Assisted Capsule Endoscopy.  Endoscopy. 2004;  36 746