I think we have several questions, and I'll also see if Dr. Cave and Dr. Vance are on as well, so please feel free to chime in. So, Dr. Harris, if you have a patient who's ingested a capsule, how do you ensure that the capsule exits the stomach? Do you, you know, do you do any certain positioning, or what, I guess, what maneuvers do you use? Oh, to make sure that the patient has the capsule. I mean, I think one of the important things when we do a capsule is the patient needs to move around. We haven't really talked about that today. You know, we have more problems when patients are in bed all the time. That's why if you have any concerns that the patient is not going to have delayed motility in the stomach, that you actually use the introductory capsule system to do it. I mean, you can see when the change occurs when it goes from the stomach to the small bowel because you can see the villi. That's what helps you to determine, although there are times when the capsule goes back and forth, and you have to kind of keep that in mind when you're watching the capsule. You have to kind of start your viewing of the small bowel when it makes its second entrance in, and hopefully final entrance into the small bowel to look at the rest of your small bowel. Yeah. Great points, Dr. Harris. Yes, because if you want to have an accurate small bowel transit time, you want to make sure that you only factor in that, the true small bowel transit, because yes, the absolute right can bounce back and forth. Do you use anything else? Like, for instance, what about real-time viewer? Does giving promotility agents help? So, you know, there's controversy about whether promotility agents, you know, work. And there's perhaps a downside, you know, because you might think a patient has a slow transit and then that promotility agent ends up shooting the capsule through the small bowel. So, you have to, I think, kind of consider the whole point of view. I haven't, there are very few incidences when I've used it. It's just something that appears in the literature. I'd be interested in hearing what other small bowel capsule experts have encountered, but I don't think in our institution, we've used it too often. You know, we do love to use erythromycin when someone is bleeding and we're going to look in their stomach, but I don't know if I've used it too much for capsule. Great. Dr. K? Yeah. So, I've used the Real-Time Viewer in research settings, and by that I mean for patients really who come into the ED, we drop a capsule right away before we do any upper or lower, and we usually will wait 40 minutes to an hour and then just make sure it's into the small bowel. That's the predominant use I've made of it. Otherwise, it's not particularly helpful. Great. When we're placing it endoscopically, we will use it to make sure that we've launched it into the small bowel. That's another time that I use the Real-Time Viewer. Yep. Great points. All right. So, I think this is a, so how long do you think the small bowel is? That's a question in the chat. Isn't it rumored to be 20 feet? That's what I've always quoted. It's pretty variable, I think, in terms of time. Figures are quoted between 12 and 20 feet. It's obviously a very elastic organ, so you can stretch it as long as you like, so it's impossible to give a real length to the organ. Yeah. And I think I go more by the metric system, so I absolutely agree. I think four to seven meters is what's quoted, so really a big variation. I don't know what, Dr. Ackerman, what do you think about the spinal entroscopy and your experience? Oh, yeah. I've always quoted five to seven meters myself, and I don't know where that number comes from. It's a number that I throw out there, so it's a, I thought it was an interesting question and because I'm not sure there is a good answer for it. I've also heard that it's related to height, but I don't know if that's true. I would say in my challenging balloon-assisted entroscopies, when I can get to where I need to, I just assume that it's a longer small bowel. One of our attendees said that they find it very challenging to see the cecum when there's fecal material in the terminal ilium, so do you have any advice on, you know, number one, identifying the cecum, so making sure that capsule is complete, and then just visualization in that area? So, you know, things can actually spend a long time in the terminal ilium. You can start seeing the lymphoid hyperplasia. I do look for, like, the sort of rosette sign that's talked about in the literature for, you know, the capsule, but the capsule can actually spend a fair amount of time, you know, right at the ileocecal valve, and I kind of look for, you know, the change in vascularity and the fact that there's no villi in the cecum to kind of use the, those features to identify the cecum, and sometimes it's very challenging because you see a lot of stool in that area, there's a pooling of stool, and so it comes, I think it's very difficult sometimes to actually say, oh, yes, this is, like, the very first cecum for you, but I kind of look for the smoothness of the mucosa and the vascularity and the loss of villi as my way of judging the cecum. Excellent. Dr. Cave? Yeah, I agree. It can be very difficult, but perhaps it doesn't matter all that much. No. As long as it enters the… Right. You clearly are in the colon. That's really the important point. Absolutely. And then, again, I think this should be a very quick, hopefully quick answer. So, what do you do with the most common, you know, the punctate red spots that you see? Well, they are of uncertain significance. I think you have to kind of take it in the whole context. They're there. They could represent… I think you look at the history, too. I think it's very important to always keep in mind the history. Is that patient using a more proportionate use of NSAIDs that maybe those are an enteritis? You know, is this an enteritis setting? But in iron deficiency anemia, I would say if you see those and the patient bleeds again, you may want to repeat your capsule. As Dr. Cave was saying, it's a fairly benign procedure. You know, you want to see if you can catch the bleeding, so you do it again. So, I would make a comment on the red spots. If they're generally isolated, I think they're single intravenous hemorrhages. And then if you get them in a cluster, that's more indicative of an inflammatory process, be it NSAIDs…well, NSAIDs certainly can cause the single intravenous hemorrhages, which are fairly widespread but not focused. If they're focused in a particular area, then I think inflammatory processes. Excellent. And I would also add, so if we have, say, a younger patient, especially a male with iron deficiency anemia, I think just finding red spots, I wouldn't stop there. I'd do much more of a comprehensive evaluation, maybe even including cross-sectional imaging, because those are the patients where you don't want to miss significant lesions, including tumors. If we don't see anything else, no P1 lesions, then I think maybe the red spots merit some additional evaluation and treatment. But for the most part, I think overall, we consider those not high risk, as Dr. Harris mentioned, maybe lesions of unclear significance. All right. And so, there was a question about timing of capsule. So, with reading time about 45 to 60 minutes, and you have to review the chart and do the report, how much time are you allotted to do the capsule? Because I think institution is trying to standardize capsule reading time. I would say it takes me about 5 to 10 minutes to go through the history and capture. You know, I target certain things. You know, you can't read everything. I look for the consult note. I look for maybe the last progress note. I look for the colonoscopy report, the upper endoscopy report. You know, look at the hemoglobin hematocrit, you know, the patient presentation. And then it usually takes me about 45 minutes to, you know, read the whole capsule and make up the report. So, I think an hour is pretty reasonable. Yeah, I would agree with that. It's actually doing the review, which I tend to do afterwards so I'm not biased as to what I'm looking for. So, I'll read the capsule, then look for, you know, the indication and so on, and then write the report. And it's the report writing and getting the background, which is, particularly if you're going to make sensible management recommendations, that's what takes the time. Absolutely. And then, so another question about what is the false negative in detecting Crohn's disease with capsule? So, what we know is based on the literature, capsule has a very high sensitivity for inflammation. So, it's a good test to rule it out. So, it has a very high negative predictive value. But on the other hand, the sensitivity is low. So, any other thoughts? Dr. Cave, Dr. Harris? No. There is something which I can pull up some slides later on, perhaps. There is a condition which has been ignored in the United States but is well described in Korea and Japan called CNSU or CMUSE, depending on where it comes from. I finally, after many years of trying, got a paper published on this in Digestive Diseases, which has just been published. It's the first one of any magnitude in the West. And there are various features which, as I say, we have time and I can pull up some of the slides. And the ELSAs are very different from those seen in Crohn's. They're much more similar to those seen with NSAIDs. And the process is non-transmural. So, you don't get the complications of fistula relapses formation. And also, you cannot see it on regular imaging. Absolutely. Great points. Anything to add, Dr. Harris? There was a question about differentiating, you know, ulcers in NSAID use versus Crohn's. And I think you have to use the clinical context and the whole picture and do your cross-sectional imaging to really know that. But I will say that if you don't really see anything on cross-sectional imaging, that seeing those ulcers in those diaphragms are basically that can, you know, lead you to think more about NSAID-related ulcerations. Absolutely. Absolutely. And I think, too, if you're suspicious and you want to evaluate a patient with suspected Crohn's with capsule, very important to advise them to stop all NSAIDs for at least eight weeks before we go ahead and have them undergo the test. So, can panelists… Oh, sorry, Dr. K. Go ahead. One other question for Lucinda. In a small percentage of very elderly patients without dysphagia, they still get retention of the capsule in the esophagus. Have you seen that, and have you investigated it from the motility standpoint? I've seen it retained for up to eight hours. I know. Yeah, we have seen, I think, some rare cases of that. I don't…you know, I haven't really investigated it. So, just like I tend to see with the elderly patients, though, I think we tend more in…we see them more in the hospital setting, so I think they tend to get the capsule introduced via the introduction system. So, I think that's why we're bypassing some of those patients, but it's a good point, and it's something that people should think about. Excellent. And Michael just gave, I think, the two-minute warning, but I have one question I think I'd be very interested to hear your insights. So, can panelists quickly summarize pre- and post-ingestion instructions for patients in terms of PrEP or no PrEP, simethicone, clear, and solid PO intake? It would be interesting to see the range. Well, I generally advise patients to stop eating anywhere between 8 and 12 hours before the endoscopy. I…let's see…the simethicone is not standardly used, but I think that's a decision that's kind of made by your endoscopy team. We've done the study that looked at PrEP versus no PrEP, and we didn't find a significant difference. The only time I think I would make an exception is if you do a study and there's no PrEP and you did find a lot of debris, then I might extend the fasting time and perhaps do a PrEP in that patient. But as Dr. Cave said, it's a major disincentive for the patient doing the capsule, so I think you don't want to do it first. I think you want to try and not do it and see what you get. And then for…it's clear fluids after two hours and four hours for any solid, and it's a light meal. Not go out and have a French eight-course dinner. Yes. Dr. Cave, anything else? Yeah, so very similar. Nothing by mouth, PrEP clear liquids from dinnertime the night before. Swallow the capsule two hours later, they can have liquids. Four hours later, they have a light meal. I don't use any adjuncts, somethacone or other prokinetics, unless there's a compelling reason to do so. Thank you so much. I would just add one other comment that Lucinda made about the MRI. I haven't published it, but I did the experiment that's essential. I took a capsule, put it in a plastic container, and put it in an MRI magnet to see what happened. And all it did was to turn lazily around. There's so little ferrous material in it. This does not necessarily apply to the ANX magnetic control capsule, but the current SP3s and all the other ones have got so little ferrous material in it, it's no threat whatever. Please publish that. It's so great to hear it didn't come ripping out of the bag. Yes. Like your oxygen bottle. That would be good to publish. It's like using the capsule in patients with pacemakers. We now know it's safe.

capsule endoscopy

Crohn's disease

gastrointestinal diagnosis

patient mobility

bowel preparation