There were a couple of quick questions that I thought we could just fire at you, rapid fire, if you don't mind. Well, you know, there is a…in the case of a capsule not passing, do you use a colon-bowel prep, was a question? Yes, so, do you give the bowel prep, you know, to make the pill capsule that possibly passed away? Yeah. I use that sometimes or, you know, like if it's more than two weeks, then, you know, before trying to…number one, like, if the patient is symptomatic or asymptomatic, right? If the patient is asymptomatic, then there is no reason to kind of do that. If there are no signs and symptoms of bowel obstruction, we have had pill cams that were deployed about three years or four years before, you know, that were still there and the patients were asymptomatic. But, you know, like if they're having any bowel obstruction type of symptoms and obviously, like you either send them to the surgery or try to retrieve the pill cam, like with anthroscopy. So theoretically, purging the bowel, you know, it may move, but I haven't seen anything, you know, solidly that it really helps with that and we have to use bowel preps. Can you determine that…one of the questions was, can you distinguish between jejunum and ileum? What are your thoughts on that, you know? So for the jejunum, you know, you can distinguish between those two anatomical sites. So the jejunum has a lot of rely, so you see the velvety appearance and then by the time you get into the proximal ileum, you see the bowel coming and also the folds are spaced out and you see the lymphoid tissue there. So that's where you can tell kind of arbitrarily, okay, by now, you know, the capsule is in the proximal ileum. One of the other attendees had a question about GLP and video capsule endoscopy. Is there any data on that as far as on the small bowel passage rate? I mean, there's obviously stomach stuff, but is there stuff for…is there any data on that that you're aware of? So the study that I have quoted that. So that has…it has increased the…decreased the gastric retention time. So there is an insignificant…when patients were in the GLP-1, the diabetic patients who were taking the GLP-1, so the small bowel passage time was not much different than in those patients who were not taking GLP-1. So they have effect on the gastric passage time, but it doesn't look like, you know, they have effect on the small bowel transit time. But I think, you know, most studies… Yeah. Shabana, any questions or comments or… Yeah, absolutely. Well, I think just a few more questions. So again, a quick one. So when we give patients capsules, when do we give them simithicone? So usually we just have the patient swallow, you know, the capsule with water that has simithicone in it. So at the time of the capsule being, I guess, swallowed by the patient. Anything different from the panelists? So we don't use a simithicone in our practice, but I think, you know, what I have seen in the literature is that it is given like at the time of the capsule ingestion along with the water. Excellent. And then there's another question about, and I see this often too, where the capsule is…there's a very rapid small bowel transit. The capsule gets to the sacrum in like two hours. So do we note this in the report, and would you repeat it? Would you repeat the capsule? Yeah. Yeah. So I think it depends upon the indication, right? So if you're really worried about, you know, there is a significant finding that could have been missed because of the rapid small bowel transit time, then…and the cross-sectional imaging, you know, so the question is like, then you do the cross-sectional imaging to see like if there are any lesions that are more than a centimeter, you know, that can be diagnosed on that. But in those cases, if there is a question, then I would repeat it. Yeah. Absolutely. And then I would also add that very important to mention it in the report, because as you mentioned that, you know, gives the requesting provider a sense that, you know, lesions may have been missed because again, two-hour transit time is not really adequate to examine the entire small bowel. I think a value in repeating the capsule may not be as much as cross-sectional imaging, as you mentioned, because again, we would expect that the capsule…there won't be anything different. So we'd expect that the capsule may have the same, you know, rapid transit, but absolutely important to the sort of adjunctive testing with cross-sectional imaging. There was another question about…and actually, this was a comment, and I absolutely agree. So if a patient has a capsule and goes on to have an MRI, absolutely, there can be capsule artifact, which can mask the findings, so the MRI may not be very valuable. So if we have a patient who's referred to us by hematology, nonspecific findings, more IBS, with mild iron deficiency, anemia, what's the yield of capsule? Do we even do a capsule in those patients? And I look forward to input from all our panelists. I think, you know, the yield is low, so it would be better to start the patients on like iron supplements first, you know, to see like if they respond to that, rather than, you know, doing the pill cam. And if you think that they do not have any risk factors for any malignancy or anything like that. So that would be my take on that. Thank you, Dr. Malapalli. Dr. Cave, anyone else have any input on that? I don't need to put…yeah. So yeah, in that scenario, the yield is going to be really low. If you've just got pure iron deficiency, the detection rate of something is going to be less than 20%. If there's really a significant anemia, it goes up to maybe as much as 50. But in somebody with IBS and presumably a younger age group, the yield is going to be really small. And it's worth taking a careful history about the menstrual cycle. I would say you could use an HLA just to make sure that they have genes for celiac disease, because if they have no genes, there's usually no celiac disease. So that might be a first, easier step. That's a very good…that's a very good comment, Lucy. Thank you. Can I delve into the long-term capsule retention? We have a few patients who are asymptomatic long-term, out several years. Rupert, what do you tell people about the risk factors in those people there? I have a couple of people that are not great surgical candidates sent to me. I can't get it from above or below. It's in that no-man's land. Not a great candidate. Several years of watching and waiting, and they seem to be fine. I don't want to send them to surgery if they don't need to. How much risk are they taking on by me just watching and waiting? I would tell my patients is that, you know, the past will predict the future. Like if the pill cam has been there like without any symptoms for all these years, it is unlikely that it's going to cause any problem, because the alternative is that, you know, the surgery and they're at a high surgical risk. And then they're worried about…but, you know, sometimes that can…knowing that there is something that's in there that shouldn't be there also kind of causes sometimes somatic complaints. So they may perceive that they're having abdominal pain and everything. So I give kind of a clear guidance to them is that what are the symptoms that they need to look for. And like, obviously, you know, the symptoms are like bowel obstruction. If it's not there, you know, I wouldn't bother about it. Anything different from our panelists? Yeah, I had one patient who had two capsules on board for upwards of 10 years with no complaints and he refused to have surgery anyway, and we couldn't reach him. So leave well alone. Yeah, so I think that my strategy is if the patient's really anxious and a surgical risk, take it out either by enteroscopy or by surgery. If they're elderly, talk to them about the risks and keep them under observation. If things change, they become symptomatic, then you may have to do something. Great. Excellent. And then do you have any… Will retain capsule ring on airport detectors? I don't know. That's a great question. I don't believe they do, but yeah. You should take a handful of them through security next time, David, as I can write that one up. I'll put that in the same paper. And then do you have any… What esophageal and gastric transit times do you consider abnormal and what do you advise in your report? So the… I mean, if the pill can hasn't… I'm sorry. If the capsule endoscope hasn't reached the stomach, you know, through the entirety of the battery life, and obviously that's abnormal. But for the gastric retention time, if it's still in the stomach, like within one to two hours, so that's a prolonged gastric retention time. But, you know, like if it has reached the cecum, right? So even though it had a prolonged gastric retention time, that hasn't changed, you know, the outcome. I think those are all the questions. I think we've covered them all. Anything else from our panelists? Otherwise, Michael, do we have… Can we go ahead and take a break now? We might be a little bit of time. I have one question to the panelists. I think Dr. Harris has mentioned, you know, how to do the report and the pill can. And have any of you have the report available in probation? Yes, I use probation. So we use the same thing like in our institution. So we save those images on the server, and then there is a report that is created in the probation, and then you download those images. And then so our capsule endoscopy reports are just like the endoscopy and colonoscopy reports with pictures and everything on them. We used to have that, but then we kind of moved towards Epic. So now what we do is we do the, you know, the report within the capsule that we're using the software, and then we basically just cut and paste it into Epic. But I think probation is actually much better in my mind. I think it's just a much cleaner report. The images are much clearer. I agree with that because that's the way we used to… You know, we're at the same place. So I do agree with that. And I like the images better in the probation. They're bigger and easier to see. And then a comment from Dr. Bhatti. The CapsuleCam rep told us that they specifically advised patients not to fly with CapsuleCam, something to do with cabin pressure change and the capsule malfunctioning. That's good to know. Interesting. For patients without probation, what are the salient points to be mentioned in capsule endoscopy report? Dr. Harris? Well, I think the landmarks, what you see, and you can make summary comments like, you know, red dot seen at such and such times. And then I do an impression and plan what is my impression of the images that I see. And then the plan, sometimes the plan is as per the referring physician. But if you feel, you know, you can make a recommendation such as antegrade versus retrograde DBE, if you think that's appropriate, then I would put that in. And, of course, your signature. Thank you, Dr. Harris. And then in patients where the capsule doesn't reach the cecum, do you usually give recommendations for imaging if there's no witness passage? Yes, that they should get a picture at two weeks, just to make sure that the capsule has also exited. And I also did forget to mention that, you know, in their standard comments, we do put in like the prep quality and how the capsule was placed. Was it placed endoscopically? Was it swallowed? Those kind of comments in the beginning are also important. Thank you so much. And also thank you for sharing the updated atlas. It's in the chat for anyone who wants to get that information.

gastroenterology

capsule endoscopy

capsule retention

small bowel transit

imaging protocols