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Wireless Capsule EndoscopyWireless Capsule Endoscopy
Eric Goldberg, M.D.Assistant Professor of Medicine
University of Maryland Medical CenterApril 8th, 2006
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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.
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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.
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S.N. S.N.
Diagnosis: Bleeding AVM in Mid Jejunum
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Enteroscopy: Bleeding in Mid-Jejunum
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AVM in Mid Jejunum
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AVM Post- Argon Plasma Coagulation
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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.
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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
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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…
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Small Bowel Follow ThroughSmall Bowel Follow Through
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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
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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
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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…
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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)
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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
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““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
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GE Junction Duodenum
Jejunum Ileocecal Valve
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Phlebectasia AVM
Lymphangectasia Bleeding Lesion
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Lymphoma GIST
Polypoid Mass Polyp
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NSAID stricture Radiation Enteritis
Sprue Villous Drop Out
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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
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Average Transit TimesAverage Transit Times
• Stomach: One hour
• Small Intestine: 4 hours
• Capsule Passage: 2-3 days
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ComplicationsComplications
• Retention of capsule: 1-5%
• Bowel obstruction: .5 %
• Aspiration: Rare
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ContraindicationsContraindicationsAbsolute:• Suspected small intestinal obstruction• Pacemakers/AICD’s. • Pregnancy
Relative:• Motility disturbances: Gastroparesis/Achalasia• Small bowel diverticulosis• Poor surgical candidates
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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
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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
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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