One of the things I think today is you're going to hear a lot of things over and over, but I think repetition is good. It helps us to learn, learn better. These are my disclosures. Our objectives this morning are to discuss the step by step process of capsule endoscopy. We're going to review some video capsule endoscopy mimics and how to differentiate them. And we'll do a little overview of the different capsule types and the latest in endoscopy technology. Here we are going to start the step by step process. So as Dr. Vance already indicated, the chief reasons that we do video capsule endoscopy are obscure GI bleeding and suspected Crohn's disease. Those are our top reasons. Yes, we do use it also for incompletely responsive celiac disease, the surveillance of inherited polyposis syndromes. And also when we suspect small bowel tumors or we have abnormal imaging. And then I think we should highlight the evaluation of drug induced bowel injury. I think we don't often think enough of when patients are taking NSAIDs, we get stuck. I think sometimes I'm thinking about the upper tract, but diaphragm disease can be found and probably best on a video capsule. I think considering our clinical context when you're going to do a video capsule endoscopy is extremely important as has been highlighted, you have to think about the risk of capsule retention or small bowel obstruction. And because I'm a motility expert I think about gastrointestinal dysmotility and whether or not that capsule is going to make it to the end. The ability of the capsule to reach the colonoscopy is incomplete and up to 10 to 15% of cases and there are some things we can do may help. So the contraindications to VCE absolutely are the current bowel obstruction, but also think if a patient is about to need an MRI, you don't want to put a capsule in them because there's risk of injury to the patient if the capsule is still there. So you have to think about that as well. The relative contraindications are a partial or intermittent small bowel obstruction, gastroparesis, or difficulty with swallowing, or the presence of a Zenker's diverticulum. Now in those instances you may be able to get around that by using a VCE deployment device and putting the capsule in during upper endoscopy. If a patient is inoperable or is going to refuse surgery, I think you really need to think twice about whether or not you're going to use that video capsule. If the patient has significant dementia and is not really a good candidate for fetching out the capsule if it gets retained, I think these are all considerations that you have to make. Pregnant women has already been discussed, but the other thing I think as Dr. Pasha mentioned, you have to think about are you going to be able to get that retained capsule, are you going to be able to get that capsule if it gets retained in a pregnant person because that puts your fetus at risk. So you have to have that as a consideration. So we talked briefly about patients with pacemakers and ICD devices and also LVADs. As Dr. Vance very nicely summarized my study, I'm not going to spend a lot of time on it. But one thing I did want to emphasize, it is safe for patients with implantable electrical devices. One of the things that I think you need to pick up on is with LVADs and the technology may be evolving, but one of the problems we encountered is actually that in the patients with LVADs, we lost image time because of the LVAD. It was the opposite. The LVAD interfered with the reception of the capsule and not the other way around, which was interesting. We found that if you positioned the implantable electrical device as far away from the leads, you positioned the leads, at that time I think we were also using more the leads than the belt, then you could get around that problem. So capturing the image. You know, we've evolved to the PillCam Recorder 3. This is the device on your left-hand screen that allows both steering and real-time viewing in the PillCam system. This is the belt, what it looks like. Keep in mind, though, that in pediatric patients and patients who have a BMI greater than 43, it is recommended to actually use the array system rather than the belt. All right, let's take a look at the capsule. So we spent a little time talking about the prep that's really no longer required. As Dr. Cave recommended, simethicone can be used to try and decrease the bubbles. There has been some mention to perhaps stop meds that slow emptying two to three days before you do a capsule study if you have the luxury of planning it. And you don't necessarily, unless someone is profusely bleeding, want to stop blood thinners. But that really depends on your clinical situation. I think another important consideration that we haven't really discussed is that particularly when you're doing outpatient capsule endoscopies and even the inpatient, patients need to know what their dietary expectations are. So they cannot have clear liquids until two hours after the device is implanted. And they can have a light meal after four hours. I've dealt with some very angry patients when they found out they couldn't eat for four hours after the test. So make sure your patients know about that. And then you can consider promotility agents. It is controversial. But if you have a patient where you're worried about emptying, you can consider metoclopramide or erythromycin. There have been some studies that have done that. All right. So this is the initial view that you get when you sign into the Pell Cam. And what you're going to do is you're going to usually push Study Manager. And this on the right is what comes up when you push Study Manager. You then can select the patient that you're reading. You can go from there in doing the study. So we're going to go to the next slide. So this is kind of the array that you see at the top. When you're looking at the Pell Cam version number nine, you are going to see two buttons on your left, the View button and the Report button. So if you're going to do a viewing of the capsule, then you have some options. So there is the Quick View and the Top 100. So the Quick View is a shortened view of the entire images of interest. And there is an arrow down that you can use to select the percentage of images seen. There is also under that button a complementary Quick View. And it includes images that are not included in Quick View. This can be used if you are asked to do a quick read for someone who is bleeding and you need a quick view. They do not take the place of reading a whole capsule study, and that needs to be emphasized. That's also true of the Top 100. The Top 100 view actually shows the 100 most clinically relevant images in the Pell Cam study. And it's most likely to include ulcers, bleeding or a polyp. And this is the view that you will get when you see when you push Quick View. And you can see at the very bottom, there are red marks above the time bar, and that shows the Top 100 images. You have to select the duodenal image before you do the Quick View. That's an important concept. Once you also get the duodenal image, then you will also see the red marks that might indicate that the patient is bleeding. We talked a little bit about choosing the layout of viewing. It's really not recommended to do it single view. You'll be there a very long time. It's recommended to either use dual or quad view. And you have to, you know, do the viewing that's most comfortable for you. The important thing about the quad view is to know the order of the images. So in quad view, the images go 1, 2, 3, 4 in a counterclockwise fashion. If you use the mosaic view, which is not really recommended for reading, it's only a view for maybe looking at pathology. This is the way the images are going. They're going down and then across and down and each time. So you have to understand that's the way that they're appearing. Interestingly, the quad view maximizes the time the images are on the screen and the ability to detect pathology. So it's more the recommended view. And it's actually recommended that you actually stare at the center of the screen when you're using that view. And just to put this in a little bit of perspective, if you're watching 10 frames per second in a single view, that's equal to a rate or speed of about 20 frames per second in the quad view. That just kind of gives you a relative feel for that. So when you're ready to view your images, you select the view button. You are going to first segment your images into the landmark images, the first gastric images, the first duodenal image and the first sequel image. There is a button that is on there that you can see that says, suggest small bowel landmarks. That's not inherently accurate. I personally just prefer to go through the study and make my own images. When you find these images, you're going to see on the next slide, then a time bar changes color into turquoise for the stomach, orange for the duodenum and green for the colon. And the esophagus, if you pick it, is blue. To capture a thumbnail, you either double click on the image or right click and then you select on this time bar down here, you can select capture thumbnail. And this also has like capturing the landmarks on it as well. This is a little larger picture of the time bar and the screen. You also want to make sure that thumbnails and GI map is selected and we'll discuss those comments, those check marks a little bit later on. The dynamic player control is an optional button, but what it's emphasizing you can see where the blue arrow is pointing actually to the side of the image. And what that's pointing to is basically the speed, the one on the top is the forward speed and the one on the bottom is the backward speed. But I actually prefer using the speed buttons down here on the bottom. There is also an adjust button right here and that can adjust the sharpness, brightness and color of your images. This is just a little, you can just get another view of where the things are on the bar. I just did this so you could basically see and see the timeline here. And this also controls your speed down here and the timing. So we're going to talk about the adjust button. So that's where it is. We can see my arrow. And in the next image, there. All right, so before we go on to the adjust button, just a couple of words. You can read the esophagus, stomach and colon faster. I usually, you know, don't spend much time in the esophagus. You can even scroll on your button on the wheel of your mouse to go through the esophagus. The stomach, I usually watch it about 20 to 25 frames per second. Usually that's on the double view. And the colon I usually go through very quickly, anywhere by 30 to 40, except right after the capsule goes in. Maybe that a little slower just to make sure there's nothing in the right colon. As I said, the button for suggested landmarks isn't always accurate. I think you have to find the small bowel feed that's comfortable for you to see. And then I want to another point I want to make is that there is a spot and I'll show you in another image. There's a check mark in the upper left corner that allows saving the image for the report. So, all right. Here's again the view of the adjust button. It's up here. You can see the arrow pointing to it. When you turn it on, you can see that you can adjust the sharpness, the brightness and the color of the image. There are little sliding bars here that you can use. To turn it off, you hit the blue off button. Sorry, my images keep going. I want to point out the blue light feature. Okay. So, the blue mode is an idea of trying to accomplish sort of chromo endoscopy. So, you see that this is on the left the image before the blue light is turned on. It's the same image. And you can see that in the display that you have to turn this button on. And when you're ready to return to the white light, you have to turn it off. But the blue light can help vascular visualization of vascular and erythematous lesions. When you're reading the study, after you identify the landmarks and pick your speed, you can right click on the image and you get this menu. I gave you this enlarged version of this so you can see this and you can see that you can open the atlas. You can also edit the thumbnail after you capture the thumbnail. And you can make little comments about what you think that lesion is, a red spot, an angio dysplasia, a cholesterol spot. The atlas, as Dr. Pasha said, is actually a very nice feature. And it has images of the esophagus, the small bowel, and the colon. And it has a lot of images. To prepare for this study, I actually did take a good look at it. So here down at the bottom here, this is where you can see that these images have been clicked in the left-hand corner. These are all going to be saved to the report. And once the images are selected and the study reviewed, then you can do the report. Before we go to talking about the report, I just want to highlight in this magnified vision of the screen a few features. So on the left-hand side are both arrow and circle highlight thumbnails, much like you do when you're in probation and doing an endoscopy report. You can actually use these and point out spots within your capsule. In the center of the screen, these are the forward and back buttons. This is the timeline as well. You can see the time that the capsule is in the small bowel. And then if you want to see an enlarged view of the image that you're seeing, on the right-hand side, there's actually a zoom button. And you can zoom in. So I mentioned that I was going to talk to you about the GI map. So the GI map is actually on the left-hand. You can sort of vaguely see that there's a small bowel and a colon there. And it will become active after all landmarks are selected. And if you click on a thumbnail, it will show you where the capsule is relatively on that map. It also, this feature also shows you the gastric and small bowel transit time. So you have an idea. And then you have small bowel transit time, just to discuss that a little more fully. It's the time that from the first duodenal image to the first fecal image. And it also gives you a percentage of small bowel transit time. And so to give you what the Medtronic people say, if you're at about 40% small bowel transit time, you're likely in the distal to zoom in. But there are limitations to this feature that are based on time and motion of the capsule. So prior going to report mode, you probably do want to save your images. So you save your findings under save findings or save finding as depending upon your system. And then you can also open the findings. And this allows review of the previous images. So let's go to creating the report. So I showed you the report button way back, that's the charcoal gray button that's in the top. So when you click this button, the screen changes and you can't see it as this well on this image. I'll show it to you on a subsequent image, but what appears is a block that shows study comments that allows you to put information about the referral reason, the procedure information and the findings. We actually have our nurses put in all that information for us so that it's there. It's pretty standardized. You can create a standard menu. Also, the landmarks will go in pretty much automatically and then you can put your findings. This is what the report looks like. There's space for summary and recommendations and your signature. And then when you push preview, this is the nice report that comes out and you can actually save that to your system and transfer, copy it and paste it into an endoscopy report. So there is a template button that you can do, click the down arrow. And there are options on that for your report to change the size of the image and also a process indicator. What's also nice about this button underneath it, there's also a de-identify option. So if you need to de-identify a report for teaching purposes or create an image of 20 seconds for a presentation as Dr. Vance so nicely did in her presentation, you can do that as well. There are other top bar features that you can see when you push report, you will get the thumbnail version where you can select all your thumbnails or unselect them and you can also delete thumbnails. And this feature helps for reports and saving images. Further over on this is the Lewis score. The Lewis score is a score for Crohn's disease and judging those images. And then your Atlas button appears there as well. And you can use your Atlas there as a reference. It's another way of accessing it. So some tips and tricks for interpreting a VCE. I think it's really important to develop your systematic approach and to divide the small bowel into proximal, mid and distal thirds. You adjust the playback speed, fast scan for normal areas. A lot of this in a lot of systems is now is done kind of by the system but you can slow it down for suspicious areas. As we said, double or quad mode helps you catch subtle lesions. You wanna know your normal variance and distinguish artifacts and lymphoid tissue from pathology. You can review transit time to identify areas at risk for missing findings. Correlate the findings with the clinical history. I think this is really important. You know, a lot of us read these video capsules and we're not necessarily involved in the care of the patient. So it's really important to read the clinical data. I often will go through the consult, the procedure information to do the report before I do the report, I'll go through all of that. So I have a context on which I'm looking through this. You wanna always retract rapid transit zones in dark areas with contrast and can use your brightness adjustment. You can use your retrograde view for unclear findings or suspected missed lesions. So you can go back and forth in your studies. Don't forget that. And I think that's important. I think these are some other important basics. Dr. Cave sort of alluded to some of these. It's really important that you have appropriate lighting that's bright enough to see your keyboard, but dim enough for good movie viewing. You're watching a movie here and you want to avoid and make sure there's no glare on your screen. And so you wanna have a good screen size in order to really do a good job seeing these studies. You wanna minimize distractions, time to turn off your email and your cell phone. And I think it is important to have dedicated time to read these. It's not recommended to read these in a piecemeal fashion. You wanna perform the reads when you're well rested and they generally take 45 to 60 minutes to do a read. And it is recommended that you kind of note, don't do more than two reads a day. And I can kind of verify that. You just get fatigue. I love capsule endoscopy, but I often say it's like watching paint dry. If you don't enjoy reading, then give it up. Okay, it's not good. So I'm just gonna go quickly through some VCE mimics and how to identify them. So just remember you're seeing things in real time without the benefit of insufflation and you can see peristaltic motions. So things do go back and forth. So keep that in mind. And one of the reasons there was a question about would I recommend for a single adenoma using a capsule endoscopy to follow up that finding and I would not, okay? The reason is capsules can tumble and they can give you a retrograde view, but they also don't always see the same things each time. So you might miss the spot where the adenoma was. So I would not use it for a duodenal adenoma to follow up. Other people may have a different opinion. And then high magnification means you can see the villi as we've seen. So this is a table that I've just created of some mimics and how to differentiate them. I'm actually gonna go through these. So I'm not gonna spend time on this particular slide. So here I was talking about bile staining. So you can see in this image here, these little spots and if you wanted to figure out if they were blood or if they were actually bile, this is where your blue light comes in handy because these will look brown when you turn the blue light on. If they're blood, they have a reddish cast to them. And these are three different images of bleeding. And this second image here, this is actually a stream of blood that's coming, may not be so easy to see on this particular image. This is kind of blatant in your face bleeding. And then the last is when you see darkness like this, you're seeing melanin alive. So keep that in mind when you're trying to judge what bleeding is. And we'll talk a little bit about assessing where bleeding is coming from in one of the later slides. Dr. Cave also referenced this, air bubbles have a smooth round mobile appearance. These are not ulcers. When you see an ulcer, this is what it looks like. In this slide, it appears with a white or yellow base and it has irregular borders. Whereas when you see a bubble, it has very smooth bubbles. And this is another picture of an ulcer on the far right. Cholesterol deposits versus lymphangiectasia. So I just wanted to present this contrasting slide because as Dr. Cave said, you actually can see usually vascular changes over cholesterol deposit. It's a benign finding. It's often seen in lower and older patients. The lymphangiectasia is usually bright white, but it also can have yellow as you can see in this image. It's also a benign finding. You can often see the villi. But lymphangiectasia can have this view as well. So these are all other pictures of lymphangiectasia. Food debris versus a mass lesion. Food debris is irregular and it's mobile across frames. So that's how you can sort of tell, but it might not be a mass. I've actually seen watermelon and it looks like a mass lesion until you see that it's moving and it goes away. But watermelon looks like tissue. It was really kind of scary when I first saw it. And on the right, this is what a mass lesion looks like. It's persistent and symmetrical. So red spots versus angioectasia. What does it mean when we see a red spot? You know, you'll often see in reports, oh, this is a red spot. A red spot is usually very tiny, usually less than one millimeter. It could be a little larger, but it's very uniform in color. It can represent a range of pathologies though. It could be an angioectasia, but it might just be an enteritis or NSAID injury. And they also can be seen in portal hypertensive change. Below is the angioectasia. The difference is usually that you can see this frond-like appearance and it also could pulsate and bleed. I also want to point out venous blebs are very commonly seen and they're usually not pathologic. Okay, one of the things I think is most challenging, and I think, you know, we may have some discussion about this and input from our various faculty members is how do you tell a mucosal fold versus a submucosal mass? Folds, they change with peristalsis. Extraluminal folds are also flatter and the angle between the indentation and the luminal surface is usually greater than 90 degrees. And you don't usually see ulcerations or stretching of the mucosa on them. Whereas masses stay fixed and they often bulge into the lumen and the angle between indentation and luminal surface is less than 90 degrees. And on masses, you may be able to see ulceration or embellication in that image. The other thing is that there is a role for CT enterography or a balloon enteroscopy if this cannot be distinguished. So this a little bit, another slide, just another picture of a bulge. And the other thing you can use is in a bulge, you see non-visible lumen in the frame it appears in. It lasts less than 10 minutes. And you can consider it if it was a tumor, if greater than two of the above criteria are not meant or there are changes in color, erythema or mucosal disruptions. These are some of the things that you can use to distinguish a bulge from a tumor. Rapid transit blur versus erosions. Just blur affects the whole frame briefly. Erosions are usually localized. Vascular patterns versus active bleeding. You can see on the left two frames, these are bleeding. It usually appears as a stream, whereas the vascularity is usually constant across frames, whereas active bleeding is usually a regular pulsatile or jet stream. Active bleeding can also pool or trail along the mucosa. On the far right, you see vessels. That doesn't happen when you're seeing a vessel. So as I said, I'm gonna talk to you a little bit about thinking about when you're trying to localize a bleed. If you have proximal blood, you'll usually see that blood or clot proximately. And then you can tell that it is usually proximal to you if you kind of see melanoma more distally. You may have a distal small bowel bleed if you see a lot of bilious fluid proximately and a plume of blood or clot distally. And then think about, because you can see colonic bleeding, you're going to see bilious material throughout the small bowel. And then the blood as the capsule enters the cecum and you see brown stool in the cecum followed by blood. All right, just some key pathology images to keep in mind. So keep in mind your anatomical perspective. Where are you looking? So if you just started your small bowel, you can see the dark side of the pylorus. As Dr. Cave showed you, this is another image of seeing the dark side of the pylorus. When you're in the proximal small bowel, this is not a polyp, this is a normal papilla. And it's seen in about 5% of capsule endoscopies. You can see diverticula. And again, keep in mind where you are. You may see, if you're proximal or in the jejunum, you may see small bowel diverticula. You can also see a Meckel's diverticulum in the ileum or diverticulosis in the colon. So when you see a finding, you've got to think, where am I anatomically? Lymphoid hyperplasia, this is a benign finding that you see in the terminal ileum. I often use it as a clue that I'm getting close to going to see my first CEQL image. You can see lymphoid hyperplasia at any age, although it's more often seen in younger patients. There can be single lesions or multiple, and this is benign and requires no treatment. All right, so you can also use a video capsule to identify obscure GI bleeding. This guideline from the ASG Standards Practice Committee, looking at the role of endoscopy in the management of obscure GI bleeding. Video capsules, particularly helpful in active bleeding. And when you have active bleeding and you're not finding it and your EGD or imaging is negative, then you can use the video capsule or other techniques as well. Angioectasia, just remember that can be a very subtle finding. So the top one shows a very nice demarcated angioectasia, but if you look very closely at the bottom one, it also has the features, so it can be very blurred. So look carefully at your images. Perhaps this is when you need to magnify them and take a closer look. These are capsule findings, different capsule findings in Crohn's disease. You can see aptosulcers, denodation, the villus edema, nodularity or cobblestoning. And the ulcers can be of any type. They can be linear, they can be serpiginous, they can be stellate or confluent. And then you also can see stenosis. Celiac disease, my favorite. This is most common leucine and malabsorptive diseases. This is most common finding. But when you see this, you need to think of a few other things such as tropical sprue, autoimmune enteropathy, combined variable immunodeficiency disorder, Whipple's disease and eosinophilic gastroenteritis as well as HIV disease. The endoscopic picture is about 50 to 94% sensitive and very specific. And you can see scalloping or this is the mosaic formation. Ulcerative jejunitis is a rare but a seeable finding on capsule endoscopy. And capsule endoscopy is really in celiac disease indicated for people who have alarm systems despite a gluten-free diet. These are a couple of images of small bowel tumors and polyps. 1.2% of GI tumors are malignancies in the small bowel. Most commonly you're going to see adenocarcinomas unless you're seeing a celiac patient. Seeing them on VCE occurs about in 6% to 8% of the cases. These are usually tumors with a poor prognosis. They actually occur more in men than women. You can also see carcinoids and the most benign finding that you can see on a video capsule is a gist tumor. And this is how kind of the small bowel tumors and video capsule endoscopies. This is a proposed algorithm for suspicion of a small bowel tumor when you choose a double balloon assisted endoscopy and a small bowel capsule endoscopy. So if you have obstructive symptoms, you know you're not going to be using your small bowel capsule. And if you do, that's when you go to your cross-sectional imaging. If your small bowel capsule is negative and your clinical suspicion is high, then you go to your cross-sectional imaging. If you're a small bowel capsule, this is when you use your double balloon assisted endoscopy. And you may need to go to surgery and interoperative exploration in certain cases. And in certain cases, you may just be monitoring the patient. This is NSAID enteropathy. As I said, it can cause vassal bleeding, obstruction or perforation. Keep it in mind. These are just a few views of ulceration and diaphragm disease here. This is what you see in diaphragm disease. So in conclusion, where you've sort of seen, Dr. Cave had a nice table of the small bowel enteroscopy symptoms. These systems, these are the different systems that are currently available. These are some of the key features. The CapsuleVision is the only one with four cameras and a 360 view. The ANGST Navicam system is the latest and it's the one that uses AI to identify the images. I want you to keep in mind that there are not just video capsule endoscopy systems for the small bowel, but also for the stomach, the colon and the entire GI tract. The ANCON Navicam has been to be used in like an ED setting where you can use a magnetically controlled device for navigation in the stomach. These are some of the common features. All of them can usually stack up images to speed up reading. They all capture landmarks and thumbnails. They all do play forward, reverse and pause features. They have a quick review feature. They usually have a feature to identify suspected bleeding. The CapsuleCam is the only one that you have to actually achieve the capsule to see the images. And there are gonna be future developments in the incorporation of AI and drivable capsules. I think that's what's coming down the horizon. Further talks will also emphasize this later on today. Thank you very much for your attention.

capsule endoscopy

GI bleeding

Crohn's disease

PillCam Recorder 3

mimics

capsule retention

diagnostic gastroenterology