Published online Jul 14, 2018. doi: 10.3748/wjg.v24.i26.2893
Peer-review started: April 18, 2018
First decision: May 9, 2018
Revised: May 19, 2018
Accepted: June 16, 2018
Article in press: June 16, 2018
Published online: July 14, 2018
Upper gastrointestinal (UGI) endoscopy (gastroscopy) is the method of choice to investigate dyspepsia, but is an uncomfortable test which carries the risk of intubation and sedation. Dyspepsia is a common symptom of which potential malignant lesions are an uncommon cause. Therefore a non-invasive alternative which might appropriately select those patients who require gastroscopy in order to obtain biopsy samples for histological analysis or for endotherapy is desirable. Capsule endoscopy is well tolerated and is a first line small bowel imaging tool, but lack of control of capsule movement limits visualisation to the dependent parts of the stomach only. Control can be achieved using external magnets, but this requires operator skill and magnetic devices which may be expensive. A simpler method would be to use swallowed water as a medium in which to move the capsule in the flow of water to different dependent parts of the stomach using patient positional change.
Several techniques using magnets to control capsule movement have been developed, but movement in water flow induced by patient positional change might offer an effective, simpler and less expensive alternative which has not been studied. An assessment of the areas of the upper gastrointestinal tract a capsule endoscope is capable of visualising is necessary in order to determine if such a technique might be feasible. Were this to be so, comparative trials with gastroscopy in identifying pathology would be warranted.
Our aims were to determine the visualisation quality of different upper gastrointestinal landmarks using a capsule endoscope moved around a water-filled stomach using a novel patient positional change technique, to assess procedural completion and patient tolerance of the procedure and time taken to read and report the videos.
This was an observational study of a cohort of patients undergoing capsule endoscopy because they declined to undergo gastroscopy. Visualisation quality of different landmarks (oesophagus, gastro-oesophageal junction, cardia, fundus, body, antrum, pylorus, duodenal bulb and second part of duodenum) was scored (1-5: Poor-excellent) as was patient tolerance in terms of pain, discomfort and distress (0-10: No - intolerable). Video reading times in both standard and Quickview mode were compared.
Complete oesophagogastric examination was achieved with excellent views in all 50 patients. However, the battery-life for the UGI capsule expired before reaching D2 in 36%. Future adaptations are necessary to either promote earlier exiting of the capsule from the stomach into the duodenum (by positional change or prokinetics) or extend battery life. Reading time was lengthy, at 48 min. Using Quickview reduced this to 20 min and no pathology was missed. Further blinded comparative trials are needed to determine the reliability of Quickview in this setting. For patients, the procedure was extremely well tolerated and no complications were seen with the UGI capsule in this study.
Our study demonstrates the feasibility of achieving excellent views of the oesophagus, stomach and duodenum (when seen) using a novel nurse-led protocol to move the upper gastrointestinal (GI) capsule through a series of patient positional changes. Future randomised control trials assessing diagnostic yield against gastroscopy will be needed to demonstrate reliability. However, the results we report suggest that this protocol may be a well-tolerated and less invasive alternative means to examining the upper GI tract endoscopically.
These findings suggest that UGI capsule endoscopy is feasible, allows visualisation of all oesophagogastric landmarks and is extremely well tolerated by patients. Technological improvement, for example in battery life, is likely to ensure more reliable imaging of the duodenum. If so, the simple positional interchange technique using the UGI capsule should be compared to gastroscopy in terms of diagnostic yield. Further studies to improve video reading time are needed.