Göke, B.

Schafer, C.

English

Universität München: Elektronischen Publikationen

Do we underestimate capsule endoscopy in the upper gastrointestinal tract?

Claus Schäfer

Burkhard Göke

Crossref

Do We Underestimate Capsule Endoscopy in the Upper Gastrointestinal Tract?

Open Access LMU ( Ludwig-Maximilians-Univ. München)

Fax +41 61 306 12 34E-Mail karger@karger.chwww.karger.com Editorial  Digestion 2005;72:239–241  DOI: 10.1159/000089958  Do We Underestimate Capsule Endoscopy in the Upper Gastrointestinal Tract?  Claus Schäfer    Burkhard Göke   Medizinische Klinik II, University Hospital Grosshadern, Ludwig Maximilian University of Munich,  Munich , Germany ing. If done early in the course of the work-up, CE short-ens the time to diagnosis and spares a number of alterna-tive investigations with lower diagnostic yield. Taken together this seems appealing to doctors.  A somewhat puzzling fact is that, in the majority of studies done so far for established indications, in only a small proportion of patients does CE have a real impact on the clinical outcome – even at a higher diagnostic yield. This clearly argues in favor of focused diagnostic strategies when considering CE for a work-up. In a way this contrasts with attempts to look for additional indica-tions for CE – sometimes probably encouraged by the manufacturer with the aim to simply sell more CE de-vices. From the data presented so far we have no reason to believe that CE is of any help in the differential diag-nosis of diffuse abdominal pain. Data presented from studies in patients with Crohn’s disease and polyposis syndromes seem interesting but have not really changed the diagnostic protocols. Here, modern enteroclysis tech-niques and double-balloon endoscopy are strong compet-itors.  In this issue of  Digestion , Peter et al. present an analy-sis of the frequency of lesions picked up in the esophagus and the stomach by CE compared to previous esophago-gastroscopy (EGD) fi ndings. Although, the study has  Since the fi rst upper gastrointestinal (GI) endoscopy was performed in 1881 by Mikulicz-Radecki, marked ad-vances have been achieved in our ability to view the GI tract. The introduction of fl exible endoscopes facilitated intubation of deeper portions of the GI tract. However, for several decades endoscopy of the small bowel was rather limited to only a small portion of the closest upper bowel or tainted with a higher risk of complications when performing our so-called push endoscopies. Recently, a noninvasive method for examination of the small bowel has become available: capsule endoscopy (CE). The fi c-tion of movie makers of simply swallowing a tablet-like instrument and thereby traveling through the GI tract seems realistic. In 2001 the Given Imaging System got FDA approval in the United States. Since its introduc-tion, several studies have been performed which demon-strated a certain superiority of this method above push endoscopy in the detection of lesions leading to obscure GI bleeding  [1, 2] . The data presented to date clearly un-derline the usefulness of CE in the search for the sources of obscure GI bleeding. Pennazio et al.  [3] evaluated the sensitivity and specifi city of CE and the outcome after CE in 100 consecutive patients with obscure GI bleeding, and reported that the procedure helps in situations with ongo-ing obscure-overt bleeding or with obscure-occult bleed- Published online: November 25, 2005  Prof. Dr. Burkhard Göke  Medizinische Klinik II, Klinikum Grosshadern  Marchioninistrasse 15, DE–81377 Munich (Germany)  Tel. +49 89 7095 2390, Fax +49 89 7095 8887  E-Mail burkhard.goeke@med.uni-muenchen.de  © 2005 S. Karger AG, Basel  0012–2823/05/0724–0239$22.00/0  Accessible online at:  www.karger.com/dig  Schäfer/Göke    Digestion 2005;72:239–241 240some pitfalls (e.g. retrospective analysis, no clinical out-come reported, and the signifi cance of the reported fi nd-ings is unclear), the authors nevertheless point out that signifi cant lesions were missed at EGD and only identi-fi ed during CE. The capsule found more mucosal lesions in 9% of the patients in the stomach and in 8% in the esophagus. The authors call for a ‘re-look’ EGD in the diagnostic algorithm after a positive capsule fi nding and an earlier negative EGD. Clearly, we cannot safely rely on previous endoscopy reports produced by others (and unfortunately also by ourselves) when ongoing bleeding from the upper GI tract still prompts questions. Anyway, the question is well taken care of in the literature on how upper GI endoscopy in the search of bleeding sources cor-relates with sensitivity and specifi city.  Another arising idea is worth discussion. Is it really possible that such a capsule rapidly rushing through the esophagus and fl ipping around the stomach will be of help in the future in the diagnostic routine of the upper GI tract? Presently, the design of the capsule is made for the journey through the small intestine. The capsule rapidly passes through the esophagus with an unpredictable transmission, thus limiting the number of pictures, in particular, of the distal esophagus. Technical advances may help when a second camera is built into the device, thereby increasing the number of pictures taken in a sec-ond. The newly developed PillCam ESO Esophageal Cap-sule has already been evaluated in patients with suspect-ed esophageal disease  [4, 5] . The aim is clear: to develop CE as a screening instrument in refl ux patients. Up to now, a small pilot study has demonstrated that CE iden-tifi ed all suspected lesions found in the endoscopy before. In this study, the mean time for the passage through the esophagus was 189  8 280 s. This seems unusually slow when compared to other reports and to our own experi-ence. Another multicenter trial has compared the accu-racy (specifi city, sensitivity, positive predictive value, and negative predictive value) of CE with EGD in pa-tients with gastroesophageal refl ux disease. In this larger study 66 of 106 patients had positive endoscopic esopha-geal fi ndings, CE identifi ed esophageal abnormalities in 61 (sensitivity 92%; specifi city 95%). In contrast, several studies have raised substantial doubts after studying the distal esophagus by CE trying to fi nd an easy screening method for refl ux lesions  [6, 7] . In any case, even if the CE could reliably prove that the specifi city and sensitiv-ity is nearly the same as for EGD, at least every patient with a pathologic result needs to get a EGD for biopsyor treatment. Therefore, endoscopy rather than CE willbe offered to those with a clinical history of refl ux. Acombination of both will add signifi cant costs to thework-up.  Will there be an indication for CE before EGD, for example CE as a general screening instrument to detect Barrett’s esophagus in a population of people older than 45 years or to exclude cancer in those with dyspepsia? How will we then handle patients without pathology in the CE? Will we offer a consecutive endoscopy?  EGD still is the gold standard, safe in the hands of an experienced gastroenterologist and providing the oppor-tunity for biopsies and treatment in the same procedure. Even if a previous EGD shows no abnormalities and seri-ous concerns regarding the clinical situation remain, an-other EGD should be performed rather than choosing CE. If the patient’s comfort is the issue, new ultra-thin naso-gastric endoscopic instruments may offer an alternative. However, their potential needs to be evaluated.  Looking at the potential of CE in the stomach, things become even worse. One of the fi rst maneuvers every trainee in gastroenterology learns is to infl ate the stomach with air thereby improving the view. How can we expect that the fi ndings in CE are similar or even superior to conventional EGD in a fasted patient swallowing the cap-sule? This technical problem may explain why when look-ing up the term ‘capsule endoscopy’ in PubMed in the 500 studies published from 2004 to 2005, not one points out that CE helps to detect lesions in the stomach. Still, Peter et al. make another point in this connection. They just tell us that it is worthwhile to ‘reintroduce the cord’ if CE hints a missed fi nding after EGD. This suggestion seems adequate and does not really imply a brighter fu-ture for CE in the diagnostic work-up of the upper GI tract. For the small intestine, the double-balloon tech-nique has the potential of becoming the standard of en-teroscopy very likely replacing the conventional push  enteroscopy and intraoperative enteroscopy. It already appears to be superior to CE in the diagnosis of small-in-testinal polyps, whereas the value for diagnosing GI bleeding of obscure origin is similar  [8, 9] .    Editorial  Digestion 2005;72:239–241 241 References  1 Mylonaki M, Fritscher-Ravens A, Swain P: Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastros-copy and colonoscopy negative gastrointesti-nal bleeding. Gut 2003;  52:  1122–1126.  2 Neu B, Ell C, May A, Schmid E, Riemann JF, Hagenmuller F, Keuchel M, Soehendra N, Seitz U, Meining A, Rosch T: Capsule endos-copy versus standard tests in infl uencing man-agement of obscure digestive bleeding: results from a German multicenter trial. Am J Gastro-enterol 2005;  100:  1736–1742.  3 Pennazio M, Santucci R, Rondonotti E, Ab-biati C, Beccari G, Rossini FP, De Franchis R: Outcome of patients with obscure gastrointes-tinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004;  126:  643–653.  4 Eliakim R, Sharma VK, Yassin K, Adler SN, Jacob H, Cave DR, Sachdev R, Mitty RD, Hartmann D, Schilling D, Riemann JF, Bar-Meir S, Bardan E, Fennerty B, Eisen G, Faigel D, Lewis BS, Fleischer DE: A prospective study of the diagnostic accuracy of PillCam ESO esophageal capsule endoscopy versus con-ventional upper endoscopy in patients with chronic gastroesophageal refl ux diseases. J Clin Gastroenterol 2005:  39:  572–578.  5 Eliakim R, Yassin K, Shlomi I, Suissa A, Eisen GM: A novel diagnostic tool for detecting oe-sophageal pathology: the PillCam oesophageal video capsule. Aliment Pharmacol Ther 2004;  20:  1083–1089.  6 Neu B, Wettschureck E, Rosch T: Is esophageal capsule endoscopy feasible? Results of a pilot. Endoscopy 2003;  35:  957–961.  7 Németh A, Rácz I: Capsule endoscopy of the esophagus (abstract)? Z Gastroenterol 2004;  42:  429.  8 Matsumoto T, Esaki M, Moriyama T, Naka-mura S, Iida M: Comparison of capsule endos-copy and enteroscopy with the double-balloon method in patients with obscure bleeding and polyposis. Endoscopy 2005;  37:  827–832.  9 Yamamoto H, Kita H: Double-balloon endos-copy. Curr Opin Gastroenterol 2005;  21:  573–577. 

Comparison of capsule endoscopy and enteroscopy with the double-balloon method in patients with obscure bleeding and polyposis. Endoscopy

De Franchis R: Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases.

DE: A prospective study of the diagnostic accuracy of PillCam ESO esophageal capsule endoscopy versus conventional upper endoscopy in patients with chronic gastroesophageal reﬂ ux diseases.

Double-balloon endoscopy. Curr Opin Gastroenterol

GM: A novel diagnostic tool for detecting oesophageal pathology: the PillCam oesophageal video capsule. Aliment Pharmacol Ther

Meining A, Rosch T: Capsule endoscopy versus standard tests in inﬂ uencing management of obscure digestive bleeding: results from a German multicenter trial.

Rácz I: Capsule endoscopy of the esophagus (abstract)? Z Gastroenterol

Wettschureck E, Rosch T: Is esophageal capsule endoscopy feasible? Results of a pilot. Endoscopy

Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding. Gut

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Do we underestimate capsule endoscopy in the upper gastrointestinal tract?

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