Capsule Endoscopy Professor Anthony Morris

Transcription

1 Capsule Endoscopy Professor Anthony Morris Consultant Gastroenterologist Director, National Endoscopy Training Centre, Royal Liverpool University Hospitals President, British Society of Gastroenterology

2 Plan of the Lecture Background to Capsule Endoscopy Current use of Capsule Endoscopy Results of Capsule Enteroscopy Other Capsules and their uses Future developments in capsules Alternatives to Capsule Enteroscopy

3 Where did it develop? Prof Paul Swain (The London Hospital) Technological spin off from Israeli arms industry by Dr Iddan, Senior Engineer, Electro-Optical Section, R&D group of Israeli Ministry of Defence 1994 Combined forces 1998-GIVEN Wireless Capsule Endoscopy Nature,405, (25/5/2000)

4 Gastro-Intestinal Video ENdoscopy (Capsule Enteroscopy)

5 Diagram of components of capsule

6 Digital recorder, dipole aerials and battery

7 Dipole antennae sites

8 What are the indications for Small Bowel Capsule Endoscopy? Recurrent iron deficiency anaemia Obscure GI Bleeding Possible Crohn s, activity and extent Abnormal small bowel radiology (except strictures)?small bowel disease (malabsorption) Polyposis syndromes NOT ABDOMINAL PAIN

9 Success rate of Capsule Endoscopy (CE) in diagnosis of Suspected Small Bowel Disease Year Author n Overall +ve (%) GI Bleed +ve (%) Diarrhoea +ve (%) 2004 Canedo Sruiran Costamagna Voderholzer Adamek Average 73 76

10 Obscure GI Bleeding(All Findings) Push enteroscopy vs Capsule

11 Obscure GI Bleeding (clinically significant lesions) Push enteroscopy vs Capsule

12 Obscure GI Bleeding (All lesions &Clinically Significant) Barium vs Capsule

13 Three recent Meta-analyses 1. Marmo, Rotondano, Piscopo et al. (October 2005) Alimentary Pharmacology & Therapeutics Triester, Leighton, Leontiadis et al. (November 2005) American Journal of Gastroenterology Triester, Leighton, Leontiadis et al. (May 2006) American Journal of Gastroenterology

14 Capsule enteroscopy vs conventional modalities in diagnosis of small bowel diseases A meta-analysis Marmo, Rotondano, Bianco & Cipolletta Aliment Pharmacol & Ther papers ( ), 17 RCT 526 pts evaluated 289 for bleeding,237 Crohn s For ever 2pts CE provided 1 more diagnosis NND 2(95% CI 2 to3) 12.9% failure to see caecum 5.5% adverse events Capsule retention higher in pts with Crohn s

15 Meta-analysis of CE vs all other procedures in all small bowel disease

16 Crohn s Lesions that are visible Hyperaemic, oedematous mucosa Ulceration Apthoid Ulcers Fissures Strictures

17 Success rate in diagnosis of Crohn s in suspected IBD patients with CE Year Author n % +ve 2003 Fireman Eliakim Herrerias Chong Gee Mow 50 60

18 Capsule Enteroscopy and Crohn s Most lesions in terminal ileum Unexpected strictures do occur Unable to differentiate between Crohn s and NSAID ulcers Histology not available More pathology found by CE than any form of radiology

19 Indications for Pill Enteroscopy in Crohn s Disease High index of suspicion (in patient with diarrhoea and raised CRP and negative x- rays ) Strong family history of IBD and appropriate symptoms but negative tests Unexplained iron deficiency in quiescent Crohn s Assess extent and activity of Crohn s? Recurrence of Crohn s

20 A Meta-Analysis of the Yield of Capsule Endoscopy Compared to Other Diagnostic Modalities in Patients with Non-Stricturing Small Bowel Crohn s Disease Triester, Leighton, Leontiadis et al Am J Gastroenterol (May) Compared yield in suspected & established Crohn s

21 Capsule endoscopy vs barium radiography All, Suspected & Established Crohn s

22 Capsule endoscopy vs CT enterography All, Suspected & Established Crohn s

23 Capsule endoscopy vs ileocolonoscopy All, Suspected & Established Crohn s

24 Sensitivity analysis of Incremental Yield High quality trials of CE vs Ba radiology

25 A Meta-Analysis of the Yield of Capsule Endoscopy Compared to Other Diagnostic Modalities in Patients with Non-Stricturing Small Bowel Crohn s Disease Triester, Leighton, Leontiadis et al Am J Gastroenterol (May) Compared yield in suspected & established Crohn s 9 studies CE vs barium radiology; Yield 63 vs 23% IY 40% p<0.001 (IY= Incremental Yield) 4 studies CE vs colonoscopy with ileoscopy Yield 61 vs 46% IY 15% p= studies CE vs CT (enterography/enteroclysis) Yield 69 vs 30% IY 38% p= studies CE vs push enteroscopy IY 38% p< study CE vs MR imaging IY 22% ns

26 Advantages of capsule enteroscopy Lesion recognition very repeatable (to the second) Simple, but boring for the patient if stays in hospital Can be replayed time and again Costs approx 430 per capsule, but kit costs 25,000 Best results in investigation of three main groups; Is small bowel disease present? What is cause of obscure bleeding/anaemia? Is Crohn s or Recurrent Crohn s present?

27 Problems of the Capsule Endoscopy Time consuming to read hours (new software? min) Soporific Risk of missing lesion on fast play-back Battery may run out before lesion reached No biopsy Attracts mad patients Can not alter view, yet

28 Design, development and testing of a remotecontrolled, stereoscopic, 3 dimensional imaging, self propelled, wireless capsule endoscope Allison, Kiraly,Springer & Van Dam Abstract 762 AGA DDW May 2006 Stereoscopic images from 2 cameras (CMOS) Acoustic thrusters (3) PZT piezoelectric Currently 5x too large Speed 200mm/s Ability to go back and re-examine areas

29 What s new in Pill Endoscopy and what may come next Oesophageal double view capsule Patency (stricture finding) capsule Colonic capsule for screening launched at UEGW Oct 2006 (2 camera) Several manufacturers: Given, Olympus, Chinese(OMOM) Realtime viewing Steerable Capsule with physiological measurements Optical biopsy & Therapy delivery

30 All three current GIVEN capsules Small Bowel, Oesophageal, Patency QuickTime and a TIFF (LZW) decompressor are needed to see this picture.

31 Small bowel pill enteroscopes Currently three available GIVEN (on left) OLYMPUS (on right) CHINESE OMOM (not shown)

32 Colon Capsule

33 M2A Patency Capsule

34 Disintegration of Patency capsule

35 Use of Patency Capsule As preliminary procedure before capsule enteroscopy, instead of Barium studies Finds strictures even missed by CT enteroclysis Literature suggests most of strictures found can be passed by Capsule Enteroscope Patency Capsule can get stuck

36 Physiological and biochemical sensors Scope for the future ph, temperature, pressure, potential difference, oxygen saturation,bacterial overgrowth (Smart capsule) Combination of change in ph and temperature may correlate with inflammation Autofluorescence or enzyme linked fluorophore release (dye/drug eluting)

37 Little and large enteroscopes A Choice of Technologies

38 What has Push Enteroscopy got to offer Acts as a repeat OGD, usually by more senior endoscopist,when patient haemoglobinised Reaches 60+ cms down jejunum Takes little longer than routine OGD Permits biopsy and therapy

39 Double Balloon Enteroscopy The next phase of small bowel endoscopy

40 Double Balloon Enteroscopy (Dr Yamamoto, Tokyo) 12mm soft overtube with distal balloon 8.5mm, 2m long enteroscope with distal balloon Scope to beyond DJ Flexure, then balloon inflated Overtube slid down, balloon inflated after DJ F Scope balloon deflated, further inserted etc 2/3 intestine examined, whole bowel if used both orally and retrograde via ileo caecal valve

41 Conventional and Double Balloon Enteroscopy Push enteroscopy finds potential cause for bleeding in 60% Push enteroscopy finds lesions within range of gastroscope in 40-60% of the above Therapy can be delivered Double Balloon enteroscopy can view 2/3 or more of small bowel (beyond reach of push enteroscope) from above, and rest per anum through i.c valve Very time consuming, potential for side effects and treatment

42 Double Balloon Enteroscopy Advantages and Disadvantages Lesions can be biopsied and treated Most if not all small bowel can be reached But Time consuming Uncomfortable for patient Risk of trauma and complications

43 34 Abstracts on Double Balloon Enteroscopy at DDW in Los Angeles (May 2006) Capsule and DBE mostly complementary About the same at finding AV lesions, ulcers and masses Capsule covered more small bowel DBE permitted endo therapy Capsule used by most as a guide to either need for and direction of insertion of DBE

44 Logical sequence for subsequent investigation of IDA & Obscure GI Bleeding If no obstructive symptoms, or risk of small bowel strictures ( no NSAID use) Capsule enteroscopy to look for lesions Push or Double Balloon enteroscopy to deliver therapy If high risk of strictures (Crohn s, NSAID s, Small bowel anastomoses) SB Barium or MRI/CT Enteroclysis If strictures; Push or DB enteroscopy (DBE) If no strictures; Capsule enteroscopy (+/- Patency capsule) and Push/DBE if required

45 The future for capsule endoscopy Bound to grow in use Need to have automated lesion detection (current Hb sensing) Devolve viewing; currently consultant, SpR, or nurse May have to consider remote review from call centre in? 3rd world Many different types of capsule, even possible therapeutic

46 My form of capsule A totally addictive anxiolytic

47 How other people still view me despite Capsule Endoscopy!

48 The end