Norfolk and Waveney Clinical Policy Development Group

Clinical Threshold Policy Briefing Paper

Title: Capsule Endoscopy

Date: 2017-05-10

1. Introduction

Introduction

Capsule endoscopy is a diagnostic technique used to assess the digestive tract. In particular, its
use is supported for the examination of sections of the gastrointestinal tract that cannot be easily
visualised with other types of endoscopy (e.g. the small intestine).

The procedure involves the swallowing of a capsule that has the size and shape of a pill,
containing a camera, a light source and a wireless circuit for the acquisition and transmission of
pictures.

To ensure a clear view, the patient is asked to start fasting 12h prior to the procedure. The capsule
is ingested and subsequently advanced through the gastrointestinal tract by peristalsis, while
sending pictures to a receiver attached to the patient’s body, at a rate of 2-3 frame per second.

The capsule then passes naturally with bowel movements, and is usually excreted between 24 and
72h.

Major indications for small bowel CE

 Overt and occult obscure gastrointestinal bleeding

o Defined as bleeding of unknown origin that persists or recurs following a
bidirectional negative endoscopic evaluation of the gastrointestinal tract (71)
o It is the main indication for the use of CE over other diagnostic modalities such as
small bowel CT, MRI, push enteroscopy and angiography.(71)
o In younger patients, with higher risk of Crohn’s disease compared to the old
population, an abdomen CT prior to the use of CE is indicated to rule out stenosis.
o The overall yield of CE for OGIB is between 35% and 83% (mean of 60%) [WJGE]
o If necessary, a CE procedure can be followed by a double balloon enteroscopy, to
allow for treatment. DBE is the only diagnostic tool with similar yield for OGIB as

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 VCE, however is more invasive, can be time consuming, requires training, needs
sedation or general anaesthesia and can have a complication rate of up to 4.3%.
o Even in the case of negative CE, if a lesion is suspected or there is persistent
bleeding, a repeat CE or DBE should be considered. In patients with rebleeding
after a negative or nondiagnostic CE, a repeat study had a diagnostic yield of 35%
to 75%, and alteration in management in 39% to 62.5% of patients.

----- 40. Svarta S, Segal B, Law J, et al. Diagnostic yield of repeat capsule endoscopy and the effect on subsequent patient management. Can J Gastroenterol.
2010;24(7):441-444.
41. Jones BH, Fleischer DE, Sharma VK, et al. Yield of repeat wireless video capsule endoscopy in patients with obscure gastrointestinal bleeding. Am J
Gastroenterol. 2005;100(5):1058-1064.
42. Viazis N, Papaxoinis K, Vlachogiannakos J, Efthymiou A, Theodoropoulos I, Karamanolis DG. Is there a role for second-look capsule endoscopy in patients with
obscure GI bleeding after a nondiagnostic first test? Gastrointest Endosc. 2009;69(4):850-856.
43. Bar-Meir S, Eliakim R, Nadler M, et al. Second capsule endoscopy for patients with severe iron deficiency anemia. Gastrointest Endosc. 2004;60(5):711-713.
 Suspected Crohn’s disease
o Indicated in non-stricturing CD, and reserved for cases with unexplained symptoms,
when other investigations remain inconclusive or when CE would affect the
management of the patient (111)
o Both in suspected and established CD, CE is performed after a negative
colonoscopy and ileoscopy
o CE has demonstrated a superior yield for detecting early inflammatory lesions in the
small bowel compared to all other modalities, between 18% and 96%
o It is especially useful in ruling out suspected CD, because of its very high negative
predictive value (129)
 Surveillance in patients with polyposis syndrome and detection of small bowel tumours
o Although CE can be an important tool in diagnosing small bowel tumours, it is
complementary to the traditional modalities and cannot substitute them. Consensus
statement for small-bowel capsule endoscopy(109)
 Screening and evaluation of NSAID side-effects
o CE can help in the diagnosis of small bowel lesions caused by the use of NSAIDs.
Recently, the widespread use of CE has provided supporting evidence that small
bowel lesions are more common than NSAID-induced gastropathy, in long-term
users. Yun Jeong Lim (159)
 Suspected malabsorptive syndromes such as celiac disease
o A meta-analysis has reported CE to have up to 89% sensitivity and 95% specificity
in diagnosing coeliac disease(176). However, a biopsy is needed to confirm coeliac
disease in patients with positive serologic markers, and therefore
gastroduodenoscopy remains the gold standard.

COMPLICATIONS
One of the most serious complications is capsule retention, defined as the presence of the capsule
in the bowel lumen for a minimum of 2 weeks anfter ingestion, or when the capsule is retained for
an unspecified period of time unless targeted medical, endoscopic or surgical intervention is
started.
(Cave D, Legnani P, de Franchis R, Lewis BS. ICCE consensus for capsule retention. Endoscopy
2005; 37: 1065-1067 [PMID: 16189792 DOI: 10.1055/s-2005-870264])

Overall ratio of capsule retention is as low as 1.4%, which makes the procedure acceptable. (Liao
Z, Gao R, Xu C, Li ZS. Indications and detection,
completion, and retention rates of small-bowel capsule
endoscopy: a systematic review. Gastrointest Endosc 2010; 71:
280-286 [PMID: 20152309 DOI: 10.1016/j.gie.2009.09.031])

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The retention rate has been found to be higher in patients diagnosed with Crohn’s disease and
neoplastic syndrome. This is explained by the presence of strictures or masses that narrow the
small bowel, and is behind the rationale for contraindication of the use of CE in patients with
proven small bowel obstruction, strictures or extensive Crohn’s disease.
Höög CM, Bark LÅ, Arkani J, Gorsetman J, Broström O, Sjöqvist U. Capsule retentions and
incomplete capsule endoscopy examinations: an analysis of 2300 examinations. Gastroenterol
Res Pract 2012; 2012: 518718 [PMID: 21969823 DOI: 10.1155/2012/518718]

23 Cheifetz AS, Kornbluth AA, Legnani P, Schmelkin I, Brown A, Lichtiger S, Lewis BS. The risk of
retention of the capsule endoscope in patients with known or suspected Crohn’s disease. Am J
Gastroenterol 2006; 101: 2218-2222 [PMID: 16848804 DOI: 10.1111/j.1572-0241.2006.00761.x]

Other possible severe complications are:

 Capsule perforation: usually it results from the capsule retention, and it most commonly
associated with severe Crohn’s disease.
 Capsule interference: the presence of pacemaker, ICD and LVADs is a relative
contraindication to the use of CE.
 Capsule aspiration: although very rare, some cases of bronchial aspiration of the capsule
have been reported. Patient with swallowing difficulties should be screened before the
procedure.

2. Evidence Summary

3. Recommendation for new/reviewed policy

CASES FOR INDIVIDUAL CONSIDERATION

On a case to case basis, patients might be eligible for the aforementioned procedures, in
consideration of their exceptionality. The requesting clinician must provide information to support
the case for being considered an exception, by submitting an individual funding request.

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4. References

1. NHS Choices Snoring – symptoms, causes and treatments -

http://www.nhs.uk/Conditions/Snoring/Pages/Introduction.aspx
2. Shamsuzzaman AS1, Gersh BJ, Somers VK. "Obstructive sleep apnea: implications for
cardiac and vascular disease." JAMA. 2003 Oct 8;290(14):1906-14
3. Knuiman M, James A, Divitini M, Bartholomew H. "Longitudinal study of risk factors for
habitual snoring in a general adult population: the Bussselton Health Study." Chest
2006;130:1779–83
4. Kasey K. Li "Surgical therapy for adult obstructive sleep apnea." Sleep Medicine Reviews
Volume 9, Issue 3, June 2005, Pages 201–209
5. NICE IPG 240 - https://www.nice.org.uk/guidance/ipg240/chapter/2-The-procedure
6. NICE IPG 476 - https://www.nice.org.uk/guidance/ipg476/chapter/3-The-procedure
7. Main, C., et al. "Surgical procedures and non-surgical devices for the management of non-
apnoeic snoring: a systematic review of clinical effects and associated treatment costs."
Health Technology Assessment 13.3 (2009).
8. NICE IPG 476 Comments - https://www.nice.org.uk/guidance/ipg476/documents/ip2602-
radiofrequency-ablation-of-the-soft-palate-for-snoring-consultation-comments-table2
9. NICE IPG 476 Research recommendations - https://www.nice.org.uk/about/what-we-
do/research-and-development/research-recommendations/IPG476/1
10. Tuomilehto, Henri PI, et al. "Lifestyle intervention with weight reduction: first-line treatment
in mild obstructive sleep apnea." American journal of respiratory and critical care medicine
179.4 (2009): 320-327.
11. Franklin, Karl A., et al. "The influence of active and passive smoking on habitual snoring."
American journal of respiratory and critical care medicine 170.7 (2004): 799-803.
12. Riemann, Randolf, et al. "The influence of nocturnal alcohol ingestion on snoring."
European Archives of Oto-Rhino-Laryngology 267.7 (2010): 1147-1156.)
13. Kotecha, Bhik. "The nose, snoring and obstructive sleep apnoea." Rhinology 49.3 (2011):
259-263.
14. Robertson, S., S. Loughran, and K. MacKenzie. "Ear protection as a treatment for
disruptive snoring: do ear plugs really work?." The Journal of Laryngology & Otology
120.05 (2006): 381-384.
15. Richard, Wietske, et al. "The role of sleep position in obstructive sleep apnea syndrome."
European Archives of Oto-Rhino-Laryngology and Head & Neck 263.10 (2006): 946-950.

Related NICE guidelines:

 IPG240 - Soft-palate implants - https://www.nice.org.uk/guidance/ipg240

 IPG476 - Radiofrequency ablation of the soft palate for snoring -
https://www.nice.org.uk/guidance/ipg476