Eliakim, Department of Gastroenterology, Rambam Medical Center,
Technion School of Medicine, Haifa, Israel
Correspondence to: Rami Eliakim, M.D., Department of
Gastroenterology, Rambam Medical Center, Bat Galim, Haifa, PO Box
9602, Israel 31096. email@example.com
AIM: To review and summerize the current literatue regarding M2A
wireless capsule endoscopy.
METHODS: Peer reviewed publications regarding the use of capsule
endoscopy as well as our personal experience were reviewed.
RESULTS: Review of the literature clearly showed that capsule
endoscopy was superior to enteroscopy, small bowel follow through
and computerized tomography in patients with obscure
gastrointestinal bleeding, iron deficiency anemia, or suspected
Crohn's disease. It was very sensitive for the diagnosis of small
bowel tumors and for survailance of small bowel pathology in
patients with Gardner syndrome or familial adenomatous polyposis
syndrome. Its role in celiac disease and in patients with known
Crohn's disease was currently being investigated.
CONCLUSION: Capsule video endoscopy is a superior and more sensitive
diagnostic tool than barium follow through, enteroscopy and entero-
CT in establishing the diagnosis of many small bowel pathologies.
Eliakim R. Wireless capsule
video endoscopy: Three years of experience. World J Gastroenterol
2004; 10(9): 1238-1239
The M2A video capsule endoscope (CE) (Given Imaging LTd;
Yokneam,Israel) is a wireless capsule (11 mm×27 mm) comprised of a
light source, lens, CMOS imager, battery and a wireless transmitter.
The slippery out side coating of the capsule allows easy ingestion
and prevents adhession of intestinal
contents, while the capsule moves via peristalsis from mouth to
anus. The battery provides 7-8 h of work in which the capsule
photographs 2 images per second (between 50 000-60 000 images all
together), which are transmitted to a recorder which is worn on the
belt. The recorder is downloaded into a computer and seen as a
continous video film. Since its development additional support
systems have been added- a localization system, a blood detector and
a double picture viewer. All ment to assist the interpretor of the
film and to shorten the reviewing period.
The full range of indications for CE became apperant with time.
The initial device was invented to address a need for a better
diagnostic tool for small bowel pathologies.
Obscure gastrointestinal bleeding
The most obvious and the first indication to be tested was
obscure gastrointestinal bleeding (OGIB), which occurred in 5-10% of
patients with any type of gastrointestinal (GI) bleeding. Several
peer reviewed articles and many abstracts have compared the
diagnostic yield of CE to push enteroscopy and other modalities in
patients with OGIB[1-4]. The added diagnostic yield of
enteroscopy was in the range of 25-30%, while that of CE was
significantly better (50-67%). This led Cave to propose an algorithm
in which the first method to evaluate the small bowel in a patient
with gastrointestinal bleeding with negative gastroscopy and
colonoscopy would be CE, and then according to its results, the
evaluation was continued with either push enteroscopy, angiography
or intra-operative enteroscopy. Cave suggested that
the closer the study was performed to the time of actual bleeding,
the greater the diagnostic yield of CE.
The 2nd obvious
indication was in patients with suspected Crohn's disease. Three
peer reviewed studies published in journal and some more in abstract
form demonstrated the superiority of CE compared to small bowel
follow through and entero CT in these patients[6-8]. The
diagnostic yield of CE in these patients ranged between 43-71%,
significantly better than small bowel follow through or entero CT
(<30%). Moreover CE diagnosed Crohn's disease in 6-9% of patients
that had OGIB. In patients with undetermined colitis
the use of CE changed the diagnosis into Crohn's disease in 50% of
Costamagna et al.
compared CE and small bowel radiographs in patients with any
suspected small bowel
disease, another indication for CE. CE was diagnostic
in 45% patients, and suspicious in another 40% patients, while
X- ray was diagnostic in only 20% patients.
Other indications for CE
Diagnosis of celiac disease, extent of Crohn's disease, GI
tumors, NSAID induced small bowel damage and survailance of
polyposis syndromes were currently investigated.
We have recently looked
at CE in real life. We looked at the charts of the first 160
patients reffered for CE by various doctors to 4 centers in Israel.
We found that CE was of value in patients with OGIB (65%), Crohn's
disease (55%) and chronic diarrhea (100%), but not in patients with
chronic abdominal pain.
These indications may include monitoring of small bowel
damage due to drugs and chemicals (NSAID, etc.), monitoring of
mucosal healing after various treatments (Crohn's for example),
assessing the extent of diseases (Crohn's, celiac) and monitoring/survailance
of upper or lower GI damage (esophagitis, Barrett's, polyps).
The only definite contraindication for CE was a patient with a
history of intestinal obstruction or known stricture, or a patient
who was a non surgical candidate.
Severe motility problems,
or swallowing abnormalities could also preclude the use of CE.
Initialy patients with pacemakers were excluded from CE trials, but
recent data mostly in abstract form, revealed that CE could be
safely performed in patients with pacemakers.
The major complication with CE was capsule retention or non
natural excretion (NNE) which was usually proximal to a stricture.
This happened many times despite normal small bowel X-rays. History
of NSAID usage, ischemic bowel event or known Crohn's disease,
carried higher risk for NNE. NNE that
neccesitated surgery occurred in less than 1% of all patients
and in 1.25% of patients with Crohn's disease.
Usually, there were no clinical signs or symptoms and NNE was found
when doing a plain abdominal film. Retrieval of the capsule and
ressection of narrowed segment via surgery, usually resolved the
medical problem which was detected by the retained capsule.
M2A CE is a safe, valuable, non-invasive, innovative tool for
the diagnosis and management of small bowel lesions like OGIB,
Crohn's disease, chronic diarrhea and probably other small bowel
Newer versions of CE
softwear allow us to get better localization and blood detection.
Advanced versions will allow us to get therapeutic modalities and a
shorter reading time.
Lewis BS, Swain P. Capsule endoscopy in the evaluation of
patients with suspected small intestinal bleeding: Results of a
pilot study. Gastrointest Endosc
2002; 56: 349-354
Scapa E, Jacob HJ, Lewkowicz S, Migdal M, Gat D, Glukhovsky
A, Guttman N, Fireman Z. Initial experience of wireless
capsule endoscopy for evaluating
occult gastrointestinal bleeding and suspected small bowel
pathology. Amer J
Gastroenterol 2002; 97:2776-2779
Ell C, Remke S, May A, Helou L, Henrich R, Mayer G. The first
prospective controlled trial comparing wireless capsule
endoscopy with push enteroscopy in
chronic gastrointestinal bleeding. Endoscopy 2002; 34: 685-689
Saurin JC, Delvaux M, Gaudin JL, Fassler I, Villarejo J,
Vahedi K, Bitoun A, Canard JM, Souquet JC, Ponchon T, Florent C,
Gay G. Diagnostic value of endoscopic
capsule in patients with obscure digestive bleeding: Blinded
comparison with video
push-enteroscopy. Endoscopy 2003; 35:
Cave DR. Wireless video capsule endoscopy. Clin Perspectives
Gastroenterol 2002; 5: 203-207
Eliakim R, Fischer D, Suissa A, Yassin K, Katz D, Migdal M,
Guttman N. Wireless capsule video endoscopy is a superior
diagnostic tool compared to barium
folloew through and CT in patients with suspectrd Crohn's disease.
Gastroenterol Hepatol 2003; 15:
Fireman Z, Mahajna E, Broude E, Shapiro M, Fich L, Sternberg
A, Kopelman Y, Scapa E. Diagnosing small bowel Crohn's
disease with wireless capsule
endoscopy. Gut 2003; 52: 390-392
Herrerias JM, Caunedo A, Rodriguez-Tellez M, Pellicer F,
Herrerias JM Jr. Capsule endoscopy in patients with suspected
Crohn's disese in negative endoscopy.
Endoscopy 2003; 35: 1-5
Eliakim R, Adler SN. Capsule endoscopy in Crohn's disease -
the European experience. Gastrointest Endoscopy Clin N
Amer 2004; 14: 129-137
Costamagna G, Shah SK, Riccioni ME, Foschia F, Mutignani M,
Perri V. A prospective trial comparing small bowel
radiographs and video capsule
endoscopy for suspected small bowel disease. Gastroenterology 2002;
Xu XQ and Wang XL Proofread
by Xu FM