So, um, I think we have one question in the chat, um, so, um, I tell you, wants to know, is there any concern for using capsule in patients who've had ruined by so altered small bowel anatomy. That's a great question. We can use capsule endoscopy safely in the setting as long as there's not also a history of bowel obstruction or something like that. And that's what we do to. I think capsule is very safe. You don't need a patency capsule in someone who has a ruined by. But remember that you can evaluate the excluded part of the pancreatic biliary system and the excluded stomach. So some adjunctive imaging or maybe even a balloon assisted endoscopy may be necessary for that. So another question. I think this is in the chat. Yeah. So regarding your final slide is MRE superior to CTE in terms of sensitivity and diagnostic yield for Crohn's. So it can be more sensitive in detecting earlier or milder disease. Thank you. And I think there was some data as well on MRE. I think with more proximal inflammation being a predictor of relapse, I think in patients who are smokers, younger patients as well. Dr. Cave, did you have any thing to add to that? What is your experience? MRE versus CTE? Yeah, I must say I like using the capsule in these patients because it often allows us to look in much more detail along the entire length of the small bowel. And you may find something in the T.I., but find apthoid else's throughout the small intestine. I don't think that changes prognosis of the disease, but I think it's an important feature to know about. Excellent. Thank you. And then when would you consider repeating a capsule? I see in bleeding, but any consideration for other indications? I mean, if symptoms have changed with Crohn's and you're sort of suspicious for active disease, that can be a good reason. For refractory celiac with new weight loss or changes, those are scenarios where you might consider repeating after a negative exam outside of the bleeding scenario. Absolutely, Dr. Banzai. And we do know that capsule can miss lesions, especially solitary lesions. So again, yes, if you do have a patient with ongoing symptoms, no definite explanation. I would add that it's such a benign exam and relatively inexpensive. I don't hesitate to use a capsule repetitively if I need to. Absolutely. And then let's see. A pregnancy is a theoretical relative contraindication, same as implanted cardiac devices. Yes or no? Yes, it's a theoretical contraindication. Yeah, I think there's one paper in the literature of a young woman who was eight months pregnant who developed a massive bleed from a jejunal tumor. And the capsule was deployed and found the lesion, which led to surgery and a good outcome for both mother and infant. And I have used it in rare circumstances in this setting with input from my maternal and fetal medicine colleagues. So it is more a reason for caution than an absolute contraindication. Absolutely, Dr. Banzai. I think more shared decision making and making sure the patient's aware of the risks, because I think the only concern is if the capsule gets retained. Yes. Are there any instances of obstruction from patency capsule? There was in the first generation that had just one biological plug, a biologically degradable plug. So what would happen is that if it was the wrong way around, the plug would degrade and then to a point that it would stick into the stricture and then would no longer degrade because there was no more fluid circulating around it. So that actually led to a number of cases of obstruction. The only theoretical concept now is that because it's a lactose barium mix in the capsule, if you gave it to a patient who is lactase deficient, they might get into trouble. But I don't know of any actual reports of that occurring. Great points, Dr. Cave. I think we had seen one patient in our institution who had a patency capsule. It actually led to obstruction and patient required surgery. But again, that would be extremely rare. Yes. And this is a great question as well. So what is your practice for relying on the report or reading the images yourself? What is the inter-reliability of readers? And I'm also hoping you can comment on, you know, some uniformity of reading. We talked about one, two versus four images, the rate at which we read the capsule, do we read it slow in the proximal versus distal small bowel? So I'd be interested in your thoughts on that. I'll let Dr. Vance go first and then I'll make some comments. Yeah, perfect. So I do like to reread the studies when I can, but it is often very challenging to get referring practices to send us the full videos. So I think that there is a role for that, especially if you're looking for something subtle or have grave concerns or the report is not in standard format, which is too often the case. Having landmark times and times of findings is very, very important and helpful for the deep enteroscopist to select a direction of approach rather than just where you think it might be. And Dr. Cave, I'm sure you have more to add as well. So in terms of the reproducibility of observations, there have been a couple of papers which really are quite distressing in terms of variability. It's hard to explain them because the variability has been so great. And one of the papers points out or at least suggests that blood is actually rather poorly defined. I don't know why that's the case, because with the latest AI, blood is the easiest thing to find and the most reliable finding. So I think those papers need to be done again, but certainly there is some unreliability and lack of reproducibility between readers. There's also, if you repeat the capsule, there's some lack of reproducibility, but not really at a clinically significant level, maybe 5 to 10 percent. If you're looking for what we call P1 lesions or P0 lesions, the numbers go up significantly, but certainly between experts, the reproducibility is quite good. Great points. There's one tip that can be used in terms of how fast you can read these. If you take a patient with a single lesion, ideally something like an angioictasia, and then run that part of the study at different speeds, the faster you get, there's going to be a point of extinction where you cannot see it. So you know that that is the maximum possible speed you can read it at. So if you back off that a little bit, then that gives you an idea of just what you can read at what speed. Excellent tips. I turn to Dr. Paul. Do you want to take over? Sure. I'm not sure I want to take over, but I'd be glad to. I had a couple of questions. As you know, Dave, I do a lot of hospitalized work, Dave and Iris, and first of all, thank you. Both talks were really fantastic. I learned a lot. You know, in the hospitalized patients, there's sometimes a demand for endoscopic placement of capsules. These are challenging patients. How do you work that in? Do you recommend that? When do you do it? Either one of you have thoughts on endoscopic placement of capsule in the hospitalized patients? Thoughts or pearls? Iris, do you want to go first? I think it is really helpful, particularly with patients with gastroparesis on GLP-1, where you think that you're not going to get a complete exam if you don't place it into the small bowel. We have an inpatient consultative service with all of the equipment to do that, so that's a fairly routine thing for us. We'll also sometimes consent patients who we suspect of having small bowel bleeding, and we redo their upper endoscopy and colonoscopy just for endoscopic placement during that same study. After seeing one bronchus in someone who was a little too sedated and swallowed it there, our practice has changed a bit around that. The problem is two things. One is make sure that you use a 12-hour capsule on inpatients. That reduces the incomplete transits. The second thing is placement with the advanced devices is very efficient, much more so than putting it in a net and then trying to advance it through the duodenum. The problem is that many of the elderly patients are unpredictable. Their transit times through the stomach can be very, very short or very, very long, and you can't predict it, so you have to often repeat the procedure. If you do have that scenario, then obviously you need to use some placement device in the duodenum. As a follow-up question, the timing of it, because I do a lot of the enteroscopies, the timing of your enteroscopy once you detect the bleed on a capsule, the importance of how long you should wait, what's your ideal goal, and what can you actually do, sort of comments on that. You detect the bleeding. You want to do the enteroscopy. What's your preferred timing, optimal? The ideal is to do it as soon as you can, but it's a logistical exercise usually when you can insert it into what is otherwise a busy endoscopist list. None of us, I think, do enough that you can dedicate a whole list to deep enteroscopy, and that would come up fairly infrequently anyway, just because of the volume issues. So most of the time, it's begging to get anesthesia support and our time to do the procedure. I don't think very few endoscopy, regular endoscopy units are set up to do double balloon enteroscopy. In our health system, we got the DBE device for our inpatient unit at our flagship hospital in one of our outpatient units that's connected to that. So we try to do it the next day, but practically speaking, with all of the logistical considerations we know about, that's not always feasible. But we'll swap, and one of our deep enteroscopists like myself or one of my couple of colleagues will come in and do that while sometimes the inpatient attending will cover a couple of outpatients for us. So we're usually able to get them done within sort of a couple of days. And that's our practice as well, because again, we understand the importance of the timeliness of the test, especially in patients who have dullifois and the vascular lesions. I think if a patient has inflammatory findings or polyps, I think those patients we can always schedule more semi-electively. But the bleeders are the ones we really want to get in as quickly as possible. Yeah, and the longer you wait, the less you find. So it is really important to, I think that's at least my take-home message from my experience. Absolutely. I think we have several great questions. And Eric and Michael, please keep us on track with time. So another question is, if you find a patient with a solitary small bowel adenoma on endoscopy, do you pursue capsule endoscopy in those patients? I think that depends on the setting. If there's any known history of FAP or one of the other polyposis syndromes, then you would definitely do a VCE. If it's an isolated polyp, then I'm not so sure that needs to be done. Iris? I agree. Yeah, that's our practice as well. Paul, anything else to add to that? No, that's nicely summarized by Dave. I'll agree. Excellent. So someone's asked about recommendations for an atlas of capsule findings. I think there's a great one by Kuschel, Hagenmuller, and Fleischer. That's the one that I sort of used when I started learning about capsule. Dave, any of you have any other recommendations? Yeah, there's a very good German one by Martin Kuschel. Kuschel, yeah. Perfect, yeah. And then I think even the capsule system itself has a real good set of representative images as well. So there's an atlas that's incorporated in the capsule software. And then let's see. How important is it for the radiologist to have experience in reading CT and MRE? Is there a big discrepancy between community versus academic centers? I think that's true for anything. I think any diagnostic modality, I think experience with, you know, diverse findings, more complicated findings is important. So I think, yeah, you do need a radiologist who has expertise. We get outside imaging sometimes where, you know, subtle findings are missed and our radiologists pick it up. Anything to add to that? Agree. Are there different types of patency capsules? One point. Sorry, go ahead. If somebody is bringing a video capsule endoscopy into a new facility, radiologists may not be aware of what they look like. And I think it's incumbent on the gastroenterologist to go and have a discussion with the radiologist to educate them as to what they're looking for if they get the capsule retained. Absolutely. Great point. Yes. Clinical context is so important. Yeah. Then let's see. Are centers with DBE capability overwhelmed with referrals for positive capsules at centers without DBE capability? Yes, I would say we do get a lot of referrals, probably more than we can schedule sometimes. And we rely on our referring colleagues to, you know, make sure that it's a truly, as Dave mentioned, P1 lesions where we can make a difference. Do you carve out time in the workday to read these or do you read them without block time in your schedule? We don't block time off. Those of us who are interested just work it in. We do have block times. I've got three of us read them and we pick them up when we can. Obviously, the inpatients, we try to provide a turnover within a few hours of the capsule being done. And I think one of the things that's going to change over the next few years is both Medtronix and ANX have remote reading capabilities. The current systems using things like GoToMyPC are pretty cumbersome. Although I haven't had experience of the other two, the potential for reading long distance is going to change what we do in terms of convenience. Excellent. All right, so I just got a thing. I think it looks like we've hit our time for Q&As. I know there's a few more, so we'll make sure we answer those. Maybe we can send out replies after the course, including the information on the Atlas.

capsule endoscopy

gastrointestinal safety

Crohn's disease

AI detection

Roux-en-Y surgery