Capsule Endoscopy 2005: Results of the 2005 International Consensus Conference - Introduction

Capsule endoscopy has now been approved as a diagnostic device in Europe and North America. Over the past 4 years, application of this technology has increased dramatically and at present there are over 2500 systems in service throughout the world. Despite this worldwide acceptance of capsule endoscopy as the state-of-the-art method for small-bowel imaging, numerous issues remain. At the Fourth International Conference on Capsule Endoscopy (ICCE), held in March 2005, 127 leaders in the field from around the world were asked to develop a consensus in six different areas: intestinal preparations and prokinetics; obscure gastrointestinal bleeding; inflammatory bowel disease; celiac disease; esophageal capsule endoscopy; and capsule retention. Of these expert physicians, 48 % were from Europe, 37 % from North America, 10 % from Japan, 3 % from Australia, and 2 % from the rest of the world. Each of the six groups had an advisory panel that worked in advance of the conference to compile the evidence-based material for that particular field. Each of the panel members prepared an address on a topic related to the subject, which was delivered to the group as a whole at the meeting. The issues were then opened to general discussion. The design for the consensus was thus similar to that used by the United States National Institutes of Health for the development of a “white” paper. Over two days, approximately 25 physicians in each group met and discussed in depth the issues presented by each panel. Consensus was built, and the following papers detail each of the six groups’ work and findings.

In the field of preparation and prokinetics, the authors clearly state that capsule endoscopy is costly and time-consuming and should therefore be conducted in optimal conditions. They conclude that although preparations and prokinetics potentially improve the quality of the examination, the ideal type, dosage, and timing have yet to be determined. Also, they consider that there are too few data to conclude that the use of preparations or prokinetics improves the completeness of the examination (visualization to the cecum). This working group proposes a scoring scale for future studies on bowel cleanliness and outlines the characteristics of an ideal study.

For obscure gastrointestinal bleeding, the authors affirm that capsule endoscopy is the third test to be employed, after a negative colonoscopy and upper endoscopy. An exception to this recommendation is the use of angiography in patients with massive hemorrhage. The consensus analyzed all of the published manuscripts thus far, including two papers in press - a meta-analysis of published reports on capsule endoscopy and a pooled analysis of Given Imaging research data.

The working group on capsule endoscopy in the setting of suspected Crohn’s disease agreed that capsule endoscopy is superior to all other methods in identifying subtle mucosal inflammatory changes, ulcers, or erosions in the small bowel. The consensus paper points out the need to define validated criteria for cases of suspected Crohn’s disease and suggests studies for the future. The group agrees that a scoring scale is necessary to help differentiate lesions suggestive of Crohn’s from those caused by nonsteroidal anti-inflammatory drugs or other drugs, as well as normal “background” findings in healthy individuals.

For celiac disease, the working group was limited by the paucity of published data. However, they were able to suggest two clear indications for capsule endoscopy in the setting of either suspected or known celiac disease. In suspected disease, the working group agreed that capsule endoscopy is indicated in patients with positive serology but a normal endoscopic biopsy. In patients with known celiac disease on a gluten-free diet who develop alarming symptoms or signs such as weight loss, nausea, and abdominal pain, capsule endoscopy was recommended to exclude malignancy.

Capsule retention continues to be a major concern for physicians performing capsule endoscopy, since it has been postulated that retention could cause acute small-bowel obstruction and, even without obstruction, retention could lead to a need for surgery to remove the capsule. Thus, retention could theoretically lead to surgery in a patient who otherwise might have been treated medically for the same illness. This is especially felt to be true for patients with Crohn’s disease or nonsteroidal anti-inflammatory drug (NSAID) enteropathy. The working group reviewed the available published data on capsule endoscopy to determine the true incidence of retention and the reported incidence of acute capsule impaction leading to obstruction. From a review of these data, the working group devised a statement to guide physicians with regard to retention.

Finally, the esophageal capsule endoscopy group agreed that this new technology is clearly capable of evaluating the esophagogastric junction. It offers the ability to rule out the presence of Barrett’s esophagus in patients with chronic reflux and can determine the presence of esophageal varices in cases with cirrhosis.

These consensus reports not only reveal how much has been accomplished in this new field, but also point the way for forthcoming research opportunities. These statements are clearly works in progress, and are launching points for an exciting future.