Clinical Endoscopy

Original Articles

Bowel preparation for small bowel capsule endoscopy: standard regimen with 2 L polyethylene glycol versus 1 L polyethylene glycol plus ascorbate: Riccardo Caccia, Alessandro Rimondi, Luca Elli, Matilde Topa, Flaminia Cavallaro, Carmine Gentile, Lucia Scaramella, Nicoletta Nandi, Reena Sidhu, Pinhas Eidler, Maurizio Vecchi, Gian Eugenio Tontini; Received April 22, 2024 Accepted August 3, 2024 Published online January 2, 2025; DOI: https://doi.org/10.5946/ce.2024.097 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Optimization of bowel preparation for small bowel capsule endoscopy (SBCE) is debated. Guidelines recommend 2 L of iso-osmolar polyethylene glycol (PEG) to improve SBCE visibility. We compared the efficacy of the standard 2 L PEG solution with a 1 L PEG plus ascorbate (PEG-ASC) preparation, which has already been established for large-bowel preparation.
Methods
Between October 2020 and February 2022, patients undergoing SBCE were assigned to receive 2 L PEG or 1 L PEG-ASC bowel preparation on an even- or odd-day basis. Bowel cleanliness was evaluated using the small bowel mucosal visibility scoring system (SBMVSS).
Results
Following propensity score matching using a random forest method, two comparable populations of patients treated with 2 L PEG (n=74, male 41%, 53±17 years) and 1 L PEG-ASC (n=74, male 42%, 55±21 years) were obtained from the original cohort of 221 consecutive SBCE patients. Our results showed a trend towards more frequent adequate mucosal visibility with 1 L PEG-ASC compared to 2 L PEG (small bowel mucosal visibility ≥2 in all three small bowel tertiles, p=0.07), as per the SBMVSS score. No significant differences were observed in the diagnostic yield (p=1.00), visibility score=9 (p=0.85), SBCE completeness (p=0.33), or adequate mucosal visibility in each tertile (p=0.61, p=0.74, and p=0.70 for the first, second, and third tertiles, respectively).
Conclusions
Our study suggests the non-inferiority of the 1 L PEG-ASC solution over the standard 2 L PEG for SBCE preparation.

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Endoscopic and histological characteristics of small bowel tumors diagnosed by double-balloon enteroscopy: Suleyman Dolu, Soner Onem, Zarni Htway, Farid Hajıyev, Ali Bilgen, Hatice Cilem Binicier, Ecem Kalemoglu, Ozgul Sagol, Mesut Akarsu; Clin Endosc 2023;56(1):83-91. Published online October 27, 2022; DOI: https://doi.org/10.5946/ce.2022.131

Abstract PDF PubReader ePub: Background
/Aims: Double-balloon enteroscopy (DBE) allows for the diagnoses and treatment of small bowel tumors (SBTs). This study aimed to evaluate the utility of DBE for the diagnosis and treatment of SBTs.
Methods
Patients diagnosed with SBTs who underwent DBE were included in this study. According to their endoscopic appearances, they were categorized as polyps or masses, and according to their histological characteristics, they were categorized as benign or malignant SBTs.
Results
A total of 704 patients were retrospectively analyzed, and 90 (12.8%) were diagnosed with SBTs. According to their endoscopic appearance, 48 (53.3%) had polyps and 42 (46.7%) had masses. Additionally, 53 (58.9%) and 37 (41.1%) patients had malignant and benign SBTs, respectively, depending on their histological characteristics. Patients diagnosed with polyps were younger than those diagnosed with masses (p<0.001). Patients diagnosed with benign SBTs were younger than those diagnosed with malignant SBT (p<0.001). Overall, histological diagnosis was determined using DBE in 73 (81.1%) patients.
Conclusions
DBE is a useful method for diagnosing SBTs. Additionally, the histological type of the lesion can be determined using DBE.

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Review

Recent developments in small bowel endoscopy: the “black box” is now open!: Luigina Vanessa Alemanni, Stefano Fabbri, Emanuele Rondonotti, Alessandro Mussetto; Clin Endosc 2022;55(4):473-479. Published online July 14, 2022; DOI: https://doi.org/10.5946/ce.2022.113

Abstract PDF PubReader ePub

Over the last few years, capsule endoscopy has been established as a fundamental device in the practicing gastroenterologist’s toolbox. Its utilization in diagnostic algorithms for suspected small bowel bleeding, Crohn’s disease, and small bowel tumors has been approved by several guidelines. The advent of double-balloon enteroscopy has significantly increased the therapeutic possibilities and release of multiple devices (single-balloon enteroscopy and spiral enteroscopy) aimed at improving the performance of small bowel enteroscopy. Recently, some important innovations have appeared in the small bowel endoscopy scene, providing further improvement to its evolution. Artificial intelligence in capsule endoscopy should increase diagnostic accuracy and reading efficiency, and the introduction of motorized spiral enteroscopy into clinical practice could also improve the therapeutic yield. This review focuses on the most recent studies on artificial-intelligence-assisted capsule endoscopy and motorized spiral enteroscopy.

Citations

Citations to this article as recorded by

Do all antithrombotic agents have a similar impact on small bowel bleeding?
Chung Hyun Tae, Ki-Nam Shim
Clinical Endoscopy.2025; 58(1): 80. CrossRef
Deep learning–based lesion detection and severity grading of small-bowel Crohn’s disease ulcers on double-balloon endoscopy images
Wanqing Xie, Jing Hu, Pengcheng Liang, Qiao Mei, Aodi Wang, Qiuyuan Liu, Xiaofeng Liu, Juan Wu, Xiaodong Yang, Nannan Zhu, Bingqing Bai, Yiqing Mei, Zhen Liang, Wei Han, Mingmei Cheng
Gastrointestinal Endoscopy.2024; 99(5): 767. CrossRef
Capsule Endoscopy for the Diagnosis of Suspected Small Bowel Bleeding
P. P. Polyakov, A. Ya. Alimetov, A. V. Onopriev, A. V. Avakimyan, A. Kh. Kade, S. A. Zanin, E. S. Zanina, Z. S. Popov, A. I. Trofimenko, Z. T. Jndoyan, A. A. Avagimyan
Innovative Medicine of Kuban.2023; (3): 121. CrossRef
Outcomes of Double Balloon-Enteroscopy in Elderly vs. Adult Patients: A Retrospective 16-Year Single-Centre Study
Margherita Trebbi, Cesare Casadei, Silvia Dari, Andrea Buzzi, Mario Brancaccio, Valentina Feletti, Alessandro Mussetto
Diagnostics.2023; 13(6): 1112. CrossRef

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Focused Review Series: Present and Future of Diagnosis and Management of Small Bowel Diseases Exploiting Artificial Intelligence and Advanced Endoscopy

Roles of Capsule Endoscopy and Balloon-Assisted Enteroscopy in the Optimal Management of Small Bowel Bleeding: Hani Abutalib, Tomonori Yano, Satoshi Shinozaki, Alan Kawarai Lefor, Hironori Yamamoto; Clin Endosc 2020;53(4):402-409. Published online July 30, 2020; DOI: https://doi.org/10.5946/ce.2020.143

Abstract PDF PubReader ePub

The small bowel had long been considered a dark unapproachable tunnel until the invention of capsule endoscopy and doubleballoon enteroscopy in the 21st century, which revolutionized the diagnosis and management of small bowel diseases, including bleeding. Various imaging modalities such as computed tomographic enterography, angiography, capsule endoscopy, and balloonassisted enteroscopy play vital roles in the diagnosis and management of small bowel bleeding. The choice of modality to use and timing of application differ according to the availability of the modalities, patient’s history, and physician’s experience. Small bowel bleeding is managed using different strategies as exemplified by medical treatment, interventional radiology, endoscopic therapy, or surgical intervention. Balloon-assisted enteroscopy enables endoscopic interventions to control small bowel bleeding, including electrocautery, argon plasma coagulation, clip application, and tattooing as a prelude to surgery. In this article, we clarify the recent approaches to the optimal diagnosis and management of patients with small bowel bleeding.

Citations

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Hemangioma capilar del yeyuno como causa de sangrado agudo: reporte de caso y revisión de la literatura
Martín Alonso Gómez Zuleta, Diego Alexander Cardona Botero, Juan Antonio Trejos Naranjo, Felipe Vera Polanía
Revista colombiana de Gastroenterología.2024; 39(3): 318. CrossRef
A practical approach for small bowel bleeding
Sung Eun Kim, Hyun Jin Kim, Myeongseok Koh, Min Cheol Kim, Joon Sung Kim, Ji Hyung Nam, Young Kwan Cho, A Reum Choe
Clinical Endoscopy.2023; 56(3): 283. CrossRef
Indication, Location of the Lesion, Diagnostic Yield, and Therapeutic Yield of Double-Balloon Enteroscopy: Seventeen Years of Experience
Sang Pyo Lee, Hyun Joo Jang, Sea Hyub Kae, Jae Gon Lee, Ji Hye Kwon
Diagnostics.2022; 12(9): 2224. CrossRef
Application of capsule endoscopy in patients with chronic and recurrent abdominal pain
Wei Yang, Zheng Li, Rui Liu, Xudong Tong, Wei Wang, Dongqiang Xu, Shan Gao
Medical Engineering & Physics.2022; 110: 103901. CrossRef

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Original Article

The Efficacy of 4 Liters of Clear Liquids for Small Bowel Preparation Prior to Video Capsule Endoscopy: Nicholas Placone, Runalia Bahar, Surinder Mann; Clin Endosc 2020;53(6):713-718. Published online March 31, 2020; DOI: https://doi.org/10.5946/ce.2019.213

Abstract PDF PubReader ePub

Background
/Aims: Optimal small bowel (SB) preparation for video capsule endoscopy (VCE) is controversial. Our study aimed to support the use of a specified volume of 4 liters of clear liquids for bowel preparation for VCE.
Methods
A retrospective review of 284 patients who underwent SB preparation with 2 liters of polyethylene glycol (PEG) and 284 patients who had 4 liters of clear liquid preparation. We analyzed image quality, endoscopic findings, completion rate, and transit times.
Results
The 4-liter clear liquid group had significantly higher mean image quality scores when compared to the PEG group (2.908±0.77 to 2.669±0.64, p<0.0001), as well as more studies with adequate preparation (72% to 64%, p=0.0214). Although the PEG group had more endoscopic findings on VCE (40% to 23%, p<0.0001), there was a significant difference in the indications for the procedure between the groups. There was no difference in the capsule completion rate or SB transit time.
Conclusions
Our data demonstrate significantly higher mean image quality scores when using a specified volume of 4 liters of clear liquid compared to 2 liters of PEG. This study supports the growing evidence of the effectiveness of a 4-liter clear liquid SB preparation as opposed to PEG for VCE.

Citations

Citations to this article as recorded by

Small bowel cleansing for capsule endoscopy, systematic review and meta- analysis: Timing is the real issue
Clelia Marmo, Maria Elena Riccioni, Marco Pennazio, Giulio Antonelli, Cristiano Spada, Guido Costamagna
Digestive and Liver Disease.2023; 55(4): 454. CrossRef
Disease surveillance evaluation of primary small-bowel follicular lymphoma using capsule endoscopy images based on a deep convolutional neural network (with video)
Akihiko Sumioka, Akiyoshi Tsuboi, Shiro Oka, Yusuke Kato, Yuka Matsubara, Issei Hirata, Hidehiko Takigawa, Ryo Yuge, Fumio Shimamoto, Tomohiro Tada, Shinji Tanaka
Gastrointestinal Endoscopy.2023; 98(6): 968. CrossRef
A colorectal cancer missed by colon capsule endoscopy: a case report
C. MacLeod, R. Oliphant, J. G. Docherty, A. J. M. Watson
BMC Gastroenterology.2022;[Epub] CrossRef
Value of the diving method for capsule endoscopy in the examination of small-intestinal disease: a prospective randomized controlled trial
Xianhui Zeng, Liansong Ye, Jianrong Liu, Xianglei Yuan, Shan Jiang, Minghui Huang, Xiujiang Huang, Chengwei Tang, Bing Hu
Gastrointestinal Endoscopy.2021; 94(4): 795. CrossRef
Bowel Preparation for Small Bowel Capsule Endoscopy: Is There Still a Role for Polyethylene Glycol?
Paul Collins, Neil Haslam, Anthony Morris, Thomas Skouras, Ashley Bond
Journal of Digestive Endoscopy.2020; 11(03): 215. CrossRef
Capsule endoscopy – Recent developments and future directions.
Stefania Zammit Chetcuti, Reena Sidhu
Expert Review of Gastroenterology & Hepatology.2020;[Epub] CrossRef
Ideal Method for Small Bowel Preparation before Video Capsule Endoscopy
Jun Lee, Shai Friedland
Clinical Endoscopy.2020; 53(6): 631. CrossRef

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Focused Review Series: Updates on Capsule Endoscopy from Esophagus to Colon

Current Status of Interpretation of Small Bowel Capsule Endoscopy: Su Hwan Kim, Dong-Hoon Yang, Jin Su Kim; Clin Endosc 2018;51(4):329-333. Published online July 31, 2018; DOI: https://doi.org/10.5946/ce.2018.095

Abstract PDF PubReader ePub

Capsule endoscopy (CE) has revolutionized direct small bowel imaging and is widely used in clinical practice. Remote visualization ofbowel images enables painless, well-tolerated endoscopic examinations. Small bowel CE has a high diagnostic yield and the ability toexamine the entire small bowel. The diagnostic yield of CE relies on lesion detection and interpretation. In this review, issues related tolesion detection and interpretation of CE have been addressed, and the current status of automated reading software development hasbeen reviewed. Clinical significance of an external real-time image viewer has also been described.

Citations

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A structured framework to evaluate capsule endoscope locomotion systems
Deepak Kumar Dinkar, M Hasan Shaheed, Eldrid Herrington, Kaspar Althoefer, Mohamed Adhnan Thaha
Progress in Biomedical Engineering.2024; 6(4): 042003. CrossRef
Prediction of Significant Lesions on Capsule Endoscopy in Patients with Suspected Small Bowel Bleeding: External Validation of SSB Capsule Dx Score
Tiago Lima Capela, Tiago Cúrdia Gonçalves, Bruno Rosa, José Cotter
Digestive Diseases.2024; : 1. CrossRef
Closed-loop active control of the magnetic capsule endoscope with a robotic arm based on image navigation
Bo Ye, Yingbing Fu, Shicong Zhang, Hao Wang, Guo Fang, Wei Zha, Amit Krishna Dwivedi
Journal of Magnetism and Magnetic Materials.2023; 565: 170268. CrossRef
KAPSUL ENDOSKOPİYASI İLƏ İNCƏ BAĞIRSAQ MÜAYİNƏSİNDƏ MÖVCUD VƏZİYYƏT VƏ GƏLƏCƏK PERSPEKTİVLİYİ
Həbib Həsənzadə, Amalya Həsənova Həbib Həsənzadə, Amalya Həsənova
PAHTEI-Procedings of Azerbaijan High Technical Educational Institutions.2023; 34(11): 105. CrossRef
Design and implementation of a highly integrated dual hemisphere capsule robot
Yongshun Zhang, Xu Liu, Guanxi Liu, Xuan Ji, Huiyuan Yang, Zhenhu Liu
Biomedical Microdevices.2022;[Epub] CrossRef
Preparation of image databases for artificial intelligence algorithm development in gastrointestinal endoscopy
Chang Bong Yang, Sang Hoon Kim, Yun Jeong Lim
Clinical Endoscopy.2022; 55(5): 594. CrossRef
Monitoring established Crohn’s disease with pan-intestinal video capsule endoscopy in Europe: clinician consultation using the nominal group technique
Cristina Carretero, Franck Carbonnel, Marc Ferrante, Torben Knudsen, Nancy Van Lent, Alan J. Lobo, Lucian Negreanu, Ana Vojvodic, Salvatore Oliva
Current Medical Research and Opinion.2021; 37(9): 1547. CrossRef
3D reconstruction of small bowel lesions using stereo camera-based capsule endoscopy
Seung-Joo Nam, Yun Jeong Lim, Ji Hyung Nam, Hyun Seok Lee, Youngbae Hwang, Junseok Park, Hoon Jai Chun
Scientific Reports.2020;[Epub] CrossRef
Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding
Neil B. Marya, Li Wang, Sonya Dasharathy, Vivy T. Cusumano, Tien Dong, M. Phillip Fejleh, Jennifer Phan, Adarsh M. Thaker, Ashwinee Condon, Alireza Sedarat, V. Raman Muthusamy, David R. Cave, Stephen Kim
Techniques and Innovations in Gastrointestinal Endoscopy.2020; 22(4): 178. CrossRef
A New Active Locomotion Capsule Endoscopy under Magnetic Control and Automated Reading Program
Dong Jun Oh, Kwang Seop Kim, Yun Jeong Lim
Clinical Endoscopy.2020; 53(4): 395. CrossRef
A survey on contemporary computer-aided tumor, polyp, and ulcer detection methods in wireless capsule endoscopy imaging
Tariq Rahim, Muhammad Arslan Usman, Soo Young Shin
Computerized Medical Imaging and Graphics.2020; 85: 101767. CrossRef
Follow-up on: optimizing lesion detection in small bowel capsule endoscopy and beyond: from present problems to future solutions
Michael Vasilakakis, Anastasios Koulaouzidis, Diana E Yung, John N Plevris, Ervin Toth, Dimitris K Iakovidis
Expert Review of Gastroenterology & Hepatology.2019; 13(2): 129. CrossRef
Capsule endoscopy for small‐intestinal disorders: Current status
Naoki Hosoe, Kaoru Takabayashi, Haruhiko Ogata, Takanori Kanai
Digestive Endoscopy.2019; 31(5): 498. CrossRef

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Focused Review Series: Current Status of Endoscopy in the Management of Inflammatory Bowel Disease

Balloon-Assisted Enteroscopy and Capsule Endoscopy in Suspected Small Bowel Crohn’s Disease: Hsu-Heng Yen, Chen-Wang Chang, Jen-Wei Chou, Shu-Chen Wei; Clin Endosc 2017;50(5):417-423. Published online September 29, 2017; DOI: https://doi.org/10.5946/ce.2017.142

Abstract PDF PubReader ePub

Inflammatory bowel diseases are idiopathic inflammatory diseases of two main types, Crohn’s disease and ulcerative colitis. Crohn’s disease can affect the entire gastrointestinal tract, and the distal ileum is involved in up to 70% of patients. Moreover, Crohn’s disease in one-quarter to one-third of patients involves isolation of the small bowel. Due to the nonspecific symptoms and anatomical location of the disease, small bowel Crohn’s disease is a phenotype that is particularly difficult to manage. Since the introduction of capsule endoscopy in 2000 and balloon-assisted enteroscopy in the 21st century, it is now possible to directly inspect for small bowel Crohn’s disease. However, the new modalities still have limitations, such as capsule retention and invasiveness of balloon-assisted enteroscopy. The diagnostic yields of both capsule endoscopy and balloon-assisted enteroscopy are high for patients with suspected small bowel Crohn’s disease. Therefore, earlier use of capsule endoscopy or balloon-assisted enteroscopy can help with the diagnosis and earlier treatment of these patients to avert possible disastrous outcomes.

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Reviews

Quality Indicators for Small Bowel Capsule Endoscopy: Ki-Nam Shim, Seong Ran Jeon, Hyun Joo Jang, Jinsu Kim, Yun Jeong Lim, Kyeong Ok Kim, Hyun Joo Song, Hyun Seok Lee, Jae Jun Park, Ji Hyun Kim, Jaeyoung Chun, Soo Jung Park, Dong-Hoon Yang, Yang Won Min, Bora Keum, Bo-In Lee, Korean Gut Image Study Group; Clin Endosc 2017;50(2):148-160. Published online March 30, 2017; DOI: https://doi.org/10.5946/ce.2017.030

Abstract PDF Supplementary Material PubReader ePub

Capsule endoscopy (CE) enables evaluation of the entire mucosal surface of the small bowel (SB), which is one of the most important steps for evaluating obscure gastrointestinal bleeding. Although the diagnostic yield of SB CE depends on many clinical factors, there are no reports on quality indicators. Thus, the Korean Gut Image Study Group (KGISG) publishes an article titled, “Quality Indicators for Small Bowel Capsule Endoscopy” under approval from the Korean Society of Gastrointestinal Endoscopy (KSGE). Herein, we initially identified process quality indicators, while the structural and outcome indicators are reserved until sufficient clinical data are accumulated. We believe that outcomes of SB CE can be improved by trying to meet our proposed quality indicators.

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Artificial Intelligence-assisted Analysis of Pan-enteric Capsule Endoscopy in Patients with Suspected Crohn’s Disease: A Study on Diagnostic Performance
Jacob Broder Brodersen, Michael Dam Jensen, Romain Leenhardt, Jens Kjeldsen, Aymeric Histace, Torben Knudsen, Xavier Dray
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Small Bowel Capsule Endoscopy within 6 Hours Following Bowel Preparation with Polyethylene Glycol Shows Improved Small Bowel Visibility
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Clinical Outcomes between P1 and P0 Lesions for Obscure Gastrointestinal Bleeding with Negative Computed Tomography and Capsule Endoscopy
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Optimal Diagnostic Approaches for Patients with Suspected Small Bowel Disease: Jae Hyun Kim, Won Moon; Clin Endosc 2016;49(4):364-369. Published online June 22, 2016; DOI: https://doi.org/10.5946/ce.2016.074

Abstract PDF PubReader ePub

While the domain of gastrointestinal endoscopy has made great strides over the last several decades, endoscopic assessment of the small bowel continues to be challenging. Recently, with the development of new technology including video capsule endoscopy, device-assisted enteroscopy, and computed tomography/magnetic resonance enterography, a more thorough investigation of the small bowel is possible. In this article, we review the systematic approach for patients with suspected small bowel disease based on these advanced endoscopic and imaging systems.

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Gut and Liver.2024; 18(4): 686. CrossRef
Symptoms Contributing to the Diagnosis of Small Bowel Tumors
Kozo Tsuruta, Hidetoshi Takedatsu, Shinichiro Yoshioka, Masahiro Yoshikai, Kensuke Tomiyasu, Masaru Morita, Kotaro Kuwaki, Keiichi Mitsuyama, Takumi Kawaguchi
Digestion.2023; 104(6): 430. CrossRef
Differentiation between small (< 4.5 cm) true subepithelial tumors and ectopic pancreas in the small bowel on computed tomography enterography
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Clinicopathological Features of Small Bowel Tumors Diagnosed by Video Capsule Endoscopy and Balloon-Assisted Enteroscopy: A Single Center Experience
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Computed Tomography of Common Bowel Emergencies
Kishan Patel, Nanxi Zha, Shana Neumann, Mitiadis Nicholas Tembelis, Mario Juliano, Naziya Samreen, Jawad Hussain, Mariam Moshiri, Michael N. Patlas, Douglas S. Katz
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Diagnostic and Therapeutic Capability of Double-Balloon Enteroscopy in Clinical Practice: Umit Akyuz, Filiz Akyuz; Clin Endosc 2016;49(2):157-160. Published online March 7, 2016; DOI: https://doi.org/10.5946/ce.2015.036

Abstract PDF PubReader ePub

Advances in technology have facilitated the common use of small-bowel imaging. Intraoperative enteroscopy was the gold standard method for small-bowel imaging. However, noninvasive capsule endoscopy and invasive balloon enteroscopy are currently the main endoscopic procedures that are routinely used for small-bowel pathologies, and the indications for both techniques are similar. Although obstruction is a contraindication for capsule endoscopy, it is not considered to be problematic for double-balloon enteroscopy. The most important advantage of double-balloon enteroscopy is the applicability of therapeutic interventions during the procedure; however, double-balloon enteroscopy has certain advantages as well as disadvantages.

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Double-Balloon Endoscopy in Overt and Occult Small Bowel Bleeding: Results, Complications, and Correlation with Prior Videocapsule Endoscopy in a Tertiary Referral Center
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Focused Review Series: Current Issues and Future Directionses of Small Bowel Endoscopic Evaluation

Current Status and Research into Overcoming Limitations of Capsule Endoscopy: Won Gun Kwack, Yun Jeong Lim; Clin Endosc 2016;49(1):8-15. Published online January 28, 2016; DOI: https://doi.org/10.5946/ce.2016.49.1.8

Abstract PDF PubReader ePub

Endoscopic investigation has a critical role in the diagnosis and treatment of gastrointestinal (GI) diseases. Since 2001, capsule endoscopy (CE) has been available for small-bowel exploration and is under continuous development. During the past decade, CE has achieved impressive improvements in areas such as miniaturization, resolution, and battery life. As a result, CE is currently a first-line tool for the investigation of the small bowel in obscure gastrointestinal bleeding and is a useful alternative to wired enteroscopy. Nevertheless, CE still has several limitations, such as incomplete examination and limited diagnostic and therapeutic capabilities. To resolve these problems, many groups have suggested several models (e.g., controlled CO₂ insufflation system, magnetic navigation system, mobile robotic platform, tagging and biopsy equipment, and targeted drug-delivery system), which are in development. In the near future, new technological advances will improve the capabilities of CE and broaden its spectrum of applications not only for the small bowel but also for the colon, stomach, and esophagus. The purpose of this review is to introduce the current status of CE and to review the ongoing development of solutions to address its limitations.

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Challenges and Future of Wireless Capsule Endoscopy: Jean-Christophe Saurin, Nicolas Beneche, Christine Chambon, Mathieu Pioche; Clin Endosc 2016;49(1):26-29. Published online January 28, 2016; DOI: https://doi.org/10.5946/ce.2016.49.1.26

Abstract PDF PubReader ePub

In 2015, capsule endoscopy was introduced as the main investigation method for small bowel mucosal diseases, and its role in colonic diseases has been gradually revealed. Future challenges for capsule endoscopy, besides improvements of image quality and visualization of each part of the small bowel and colonic mucosa, include the development of gastric capsules, the capacity to perform histological examination of the mucosa, and maybe in the future, some capsule endoscopy-driven therapeutics. The aim of this review was to evaluate the clinical demands and feasibility of achieving the aforementioned objectives.

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The Usefulness of Capsule Endoscopy for Small Bowel Tumors: Dae Young Cheung, Jin Su Kim, Ki-Nam Shim, Myung-Gyu Choi, Korean Gut Image Study Group; Clin Endosc 2016;49(1):21-25. Published online January 28, 2016; DOI: https://doi.org/10.5946/ce.2016.49.1.21

Abstract PDF PubReader ePub

Video capsule endoscopy (VCE) has expanded the range of endoscopic examination of the small bowel. The clinical application of VCE is mainly for obscure gastrointestinal bleeding (OGIB) and small bowel tumor is one of the clinically significant diagnoses of VCE, often requiring subsequent invasive interventions. Small bowel tumors are detected with a frequency of around 4% with VCE in indications of OGIB, iron deficiency anemia, unexplained abdominal pain, and others. Protruding mass with bleeding, mucosal disruption, irregular surface, discolored area, and white villi are suggested as the VCE findings of small bowel tumor. Device assisted enteroscopy (DAE), computed tomography enteroclysis/enterography and magnetic resonance enteroclysis/enterography also have clinical value in small bowel examination and tumor detection, and they can be used with VCE, sequentially or complementarily. Familial adenomatous polyposis, Peutz-Jeghers syndrome, melanoma, lymphoma, and neuroendocrine tumor with hepatic metastasis are the high risk groups for small bowel tumors, and surveillance programs for small bowel tumors are needed. VCE and radiological imaging have value in screening, and in selected cases, DAE can provide more accurate diagnosis and endoscopic treatment. This review describes the usefulness and clinical impact of VCE on small bowel tumors.

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Case Report

Small Bowel Stent-in-Stent Placement for Malignant Small Bowel Obstruction Using a Balloon-Assisted Overtube Technique: Daniel Popa, Jayapal Ramesh, Shajan Peter, C. Mel Wilcox, Klaus Mönkemüller; Clin Endosc 2014;47(1):108-111. Published online January 24, 2014; DOI: https://doi.org/10.5946/ce.2014.47.1.108

Abstract PDF PubReader ePub

Self-expanding metal stents are a useful therapy to palliate malignant and benign luminal gastrointestinal obstruction. Self-expanding metal stents has been widely reported for colonic, esophageal, and gastric obstruction. However, endoscopic delivery and placement to the small bowel is more challenging and difficult. This case illustrates the usefulness and technical advantages of the balloon-overtube and enteroscopy technique for the palliative treatment of neoplastic stenosis affecting the small intestine.

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Review

Guideline for Capsule Endoscopy: Obscure Gastrointestinal Bleeding: Ki-Nam Shim, Jeong Seop Moon, Dong Kyung Chang, Jae Hyuk Do, Ji Hyun Kim, Byung Hoon Min, Seong Ran Jeon, Jin-Oh Kim, Myung-Gyu Choi, Korean Gut Image Study Group; Clin Endosc 2013;46(1):45-53. Published online January 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.1.45

Abstract PDF PubReader ePub

Capsule endoscopy (CE) is considered as a noninvasive and reliable diagnostic tool of examining the entire small bowel. CE has been performed frequently at many medical centers in South Korea; however, there is no evidence-based CE guideline for adequate diagnostic approaches. To provide accurate information and suggest correct testing approaches for small bowel disease, the guideline on CE was developed by the Korean Gut Image Study Group, a part of the Korean Society of Gastrointestinal Endoscopy. Operation teams for developing the guideline were organized into four areas: obscure gastrointestinal bleeding, small bowel preparation, Crohn's disease, and small bowel tumor. A total of 20 key questions were selected. In preparing this guideline, MEDLINE, Cochrane library, KMbase, KISS, and KoreaMed literature searches were performed. After writing a draft of the guideline, opinions from various experts were reflected before approving the final document. The guideline should be regarded as recommendations only to gastroenterologists in providing care to their patients. These are not absolute rules and should not be construed as establishing a legal standard of care. Although further revision may be necessary as new data appear, this guideline is expected to play a role for adequate diagnostic approaches of various small bowel diseases.

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Special Issue Articleses of IDEN 2012

Lessons from Korean Capsule Endoscopy Multicenter Studies: Kyeong Ok Kim, Byung Ik Jang; Clin Endosc 2012;45(3):290-294. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.290

Abstract PDF PubReader ePub

Since its development, video capsule endoscopy (VCE) introduced a new area in the study of small bowel disease. We reviewed and discussed current issues from Korean capsule endoscopy multicenter studies. Main results are as follows: First, there was no significant difference in diagnostic yield according to the method of bowel preparation. Second, VCE represents a reliable and influential screening measure in patients with chronic unexplained abdominal pain and this technique could successfully alter the clinical course especially for patients with small bowel tumor. Third, the inter-observer variation in the expert group was lower than that in trainee group. Fourth, studies about the spontaneous capsule passage after retention showed 2.5% of retention rate and the size of lumen was an important factor of spontaneous passage. We need larger scale studies on the effect of bowel preparation methods on the diagnostic yield and further studies about the learning curve or unique capsule endoscopic findings for small intestinal diseases in Korean patients.

Citations

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Factors Affecting Diagnostic Yields of Capsule Endoscopy for Obscure Gastrointestinal Bleeding
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Lawrence Hookey, Jacob Louw, Michelle Wiepjes, Natalie Rubinger, Stijn Van Weyenberg, Andrew G. Day, William Paterson
Gastrointestinal Endoscopy.2017; 85(1): 187. CrossRef
Retention associated with video capsule endoscopy: systematic review and meta-analysis
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Clinical Endoscopy.2013; 46(4): 321. CrossRef

7,023 View
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A Look into the Small Bowel in Crohn's Disease: Soo Jung Park, Won Ho Kim; Clin Endosc 2012;45(3):263-268. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.263

Abstract PDF PubReader ePub

Crohn's disease (CD) is an inflammatory bowel disease that can affect the entire gastrointestinal tract, with the small bowel (SB) being the most commonly affected site. In some patients, refractory inflammation or chronic strictures of the SB are responsible for a debilitating course of the disease that might lead to severely reduced quality of life. Therefore, SB imaging is a crucial element in diagnosing and/or managing SB CD, and continues to evolve because of technologic advances. SB endoscopy (capsule endoscopy and device-assisted enteroscopy) and cross-sectional radiologic imaging (computed tomography enterography and magnetic resonance enterography) have become key players to diagnose and/or manage CD. In everyday practice, the choice of the imaging modalities is based on the presence and availability of the techniques and of experienced operators in each institute, clinical usefulness, safety, and cost. Here, SB endoscopy and radiologic imaging in suspected or known CD patients will be addressed and discussed.

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Case Report

A Case of Giant Inflammatory Ileal Polyp Removed by Double-Balloon Enteroscopy: Dae Woong Yoon, Beom Jae Lee, Jae Hyoung Lee, Jong-Jae Park, Jae Seon Kim, Young-Tae Bak, Won Jae Choi, Young Jae Mok; Clin Endosc 2012;45(3):198-201. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.198

Abstract PDF PubReader ePub

Inflammatory fibroid polyps are rare benign tumors of the GI tract, that commonly present with intestinal obstruction as a result of intussusceptions in the small bowel. A 39-year old man visited our clinic with an asymptomatic polypoid mass in the distal ileum that was identified on abdominal computed tomography for postoperative surveillance after total gastrectomy due to previously diagnosed early gastric cancer. Retrograde double-balloon enteroscopy was performed to diagnose the ileal mass and a complete resection of the polyp was performed using snare for polypectomy without complications. The final histological finding was an ileal inflammatory polyp. Balloon-assisted enteroscopy is a valuable modality to diagnose and treat small bowel lesions in lieu of surgical procedures in selected cases.

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Review

Current Advance in Small Bowel Tumors: Dae Young Cheung, Myung-Gyu Choi; Clin Endosc 2011;44(1):13-21. Published online September 30, 2011; DOI: https://doi.org/10.5946/ce.2011.44.1.13

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Small intestinal tumors are difficult challenge to gastroenterologists. The difficulty in making a diagnosis of small intestinal tumor lies in the relative inaccessibility and absence of typical presentation. New endoscopic and radiologic technologies provide clear and fine anatomical visualization of the small bowel and are approved to improve the diagnostic sensitivity and accuracy. Patients at risk of small intestinal tumors might gain a benefit from proper surveillance with this new technology. Minimally invasive therapy is now available with advance of balloon assisted enteroscopy. This review describes the general aspect of the small intestinal tumors, focusing on the new modalities for diagnosis.

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A Case of Barium Appendicitis after a Small Bowel Series: Ki Ho Yun, M.D., Hyeon Woong Yang, M.D., Se Young Park, M.D., Young Wook Yoo, M.D., Seung Yeon Na, M.D., Young Woo Lee, M.D. and Sang Woo Cha, M.D.; Korean J Gastrointest Endosc 2011;43(1):38-41. Published online July 28, 2011

Abstract PDF: Barium appendicitis is a rare complication that occurs due to barium retention in the appendix after a barium study. It is believed that retained barium in the appendix forms a barium-coated fecalith and causes barium appendicitis. A 19-year-old man visited the hospital due to melena. He underwent an endoscopy and a colonoscopy but no bleeding focus was discovered. Next, a small bowel series was performed to confirm the absence of small bowel bleeding. Two weeks later, he felt right lower quadrant pain in his abdomen and developed a fever. A blood test revealed an elevated white blood cell count. A plain abdominal radiograph indicated retained barium in the appendix. A computed tomography scan revealed a dilated barium filled appendix. Thus, the pain was thought to caused by barium retention in the appendix that precipitated acute appendicitis. He underwent an appendectomy and healed well without complications. (Korean J Gastrointest Endosc 2011;43:38-41)

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Inflammatory Pseudotumor Causing Small Bowel Obstruction in a Patient with AIDS: Hyun Soo Kim, M.D., Jae Myung Cha, M.D., Joung Il Lee, M.D., Kwang Ro Joo, M.D., Hyun Joon Jung, M.D., Chi Hoon Lee, M.D., Sung-Jig Lim, M.D.* and Ki Yong Na, M.D.*; Korean J Gastrointest Endosc 2011;42(4):250-254. Published online April 28, 2011

Abstract PDF: Small bowel obstructions are most commonly caused by adhesions, hernias, neoplasms or inflammatory stricture. Inflammatory pseudotumors are an uncommon cause of small bowel obstruction, even in a patient with acquired immunodeficiency syndrome (AIDS). We have experienced a case of small bowel obstruction caused by an inflammatory pseudotumor in a 38-year old male with AIDS. Abdominal computed tomography showed small bowel obstruction due to jejunal annular wall thickening. Surgical laparotomy showed a non-specific granulomatous inflammatory mass that could not fulfill any diagnostic criteria for a specific disease. This report describes our findings of small bowel obstruction due to an inflammatory pseudotumor and discusses the differential diagnosis of inflammatory pseudotumor in AIDS patients. (Korean J Gastrointest Endosc 2011;42:250-254)

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Jejunal Metastasis of Lung Cancer Diagnosed with Double Balloon Enteroscopy: Sun Gyo Lim, M.D., Sung Jae Shin, M.D., Kyung Hyun Koh, M.D., Sung Jun Choi, M.D., Jeong Woo Choi, M.D., Ki Myung Lee, M.D. and Jin Hong Kim, M.D.; Korean J Gastrointest Endosc 2011;42(1):47-51. Published online January 30, 2011

Abstract PDF: Metastasis from lung cancer to the small bowel is rare and this accounts for 0.2% to 0.5% of all the cases of metastasis from lung cancer. In most cases, the patients are asymptomatic and they can show signs of bleeding, intestinal obstruction, perforation and so on. A better diagnostic approach to the small bowel has recently been made possible through capsule endoscopy and double balloon enteroscopy (DBE), and they have a higher diagnostic rate for small bowel bleeding compared with that of the previous diagnostic tests. DBE makes it possible to diagnose precisely due to the high quality endoscopic images and biopsy specimens. In addition, therapeutic DBE with a 2.8 mm channel enables performing more kinds of therapeutic procedures than diagnostic DBE with a 2.2 mm channel. If small bowel metastasis is suspected on ¹⁸FDG-PET/CT, then DBE can be considered for making a pathologic diagnosis. We report here on a case of small bowel metastasis from non small cell lung cancer in a 39-year-old woman who complained of hematochezia and we review the relevant literature. (Korean J Gastrointest Endosc 2011;42:47-51)

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Polyarteritis Nodosa Localized in Small Intestine: A Case Report: Byung Hoon Lim, M.D., Ji Sun Jang, M.D., Jung Won Kim, M.D.*, Se Jin Jang, M.D.^†, Sung Hoon Kim, M.D., Jei So Bang, M.D., Soo Hyun Yang, M.D. and Jong Hoon Byun, M.D.; Korean J Gastrointest Endosc 2010;41(2):113-117. Published online August 30, 2010

Abstract PDF: Polyarteritis nodosa is a systemic necrotizing vasculitis that affects mainly small and medium-sized arteries that involve multiple organs. In addition to the systemic involvement of classical vasculitis, localized vasculitis involves blood vessels within a confined vascular distribution or single organ without clinical evidence of generalized inflammation. Localized vasculitis of the gastrointestinal tract is a rare entity. In particular, a limited involvement of the small bowel is an unusual manifestation of polyarteritis nodosa. In this report, we describe a case of biopsy-proven polyarteritis nodosa presenting as small bowel bleeding without other systemic manifestations. (Korean J Gastrointest Endosc 2010;41:113-117)

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Follow-up after Double Balloon Enteroscopy in Patients with Suspected Small Bowel Bleeding: Focused on the Rebleeding Rate: Sun-Jin Boo, M.D., Jeong-Sik Byeon, M.D., Kee Don Choi, M.D., Byong Duk Ye, M.D., Dong-Hoon Yang, M.D., Soon Man Yoon, M.D., Kyung-Jo Kim, M.D., Seung-Jae Myung, M.D., Suk-Kyun Yang, M.D. and Jin-Ho Kim, M.D.; Korean J Gastrointest Endosc 2010;40(3):157-163. Published online March 30, 2010

Abstract PDF: Background
/Aims: Double balloon enteroscopy (DBE) is an effective modality for making the diagnosis and managing suspected small bowel bleeding. However, there is limited data on the follow-up results after DBE. The aim of this study was to evaluate the long-term clinical outcome after DBE in patients with suspected small bowel bleeding.
Methods
We retrospectively analyzed the rebleeding rate of 60 consecutive patients (M：F=39：21, age: 13∼85 years) who underwent DBE because of suspected small bowel bleeding at Asan Medical Center during a 3 year period.
Results
The median follow-up period was 552 days. Bleeding sources were detected by DBE in 41 patients. The cumulative rebleeding rate at 6, 12 and 24 months was 22%, 27% and 30%, respectively. There was no significant difference in the cumulative rebleeding rate between the patients with bleeding sources detected by the initial DBE and those without bleeding sources detected by the initial DBE. The cumulative rebleeding rate at 6 and 12 months was significantly higher for the patients with vascular or superficial mucosal lesions than for the patients with tumors or other lesions (p=0.013).
Conclusions
The rebleeding risk after DBE is not low for patients with suspected small bowel bleeding. The rebleeding risk is especially high for patients with vascular or superficial mucosal lesions, and this may necessitate careful follow-up. (Korean J Gastrointest Endosc 2010;40:157-163)

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Small Bowel Obstruction and Capsule Retention by a Small Bowel Ulcer That Was Not Found on Capsule Endoscopy: Kwan Sik Park, M.D., Ji Hyun Kim, M.D., Choong Heon Ryu, M.D., Hyo Rim Seo, M.D., Yun Jung Choi, M.D., Seoung In Ha, M.D., Sang Heon Lee, M.D. and Sang Young Seol, M.D.; Korean J Gastrointest Endosc 2010;40(1):58-61. Published online January 30, 2010

Abstract PDF: Capsule endoscopy (CE) is a valuable modality for directly examining the small bowel in a relatively noninvasive and safe manner. CE is being increasingly used for obscure gastrointestinal bleeding, Crohn's disease, drug induced ulcer and small bowel tumor. Although capsule retention is a relatively infrequent complication, small bowel obstruction and strictures have been considered contraindications to CE. But some authors have reported that capsule endoscopy can be safely used to help identify the etiology and site of small bowel obstruction, and the retention of the capsule indicates the presence of a lesion requiring surgery. We report here on a case of small bowel obstruction and capsule retention by a small bowel ulcer, and the small bowel ulcer was not found when performing capsule endoscopy. (Korean J Gastrointest Endosc 2010;40:58-61)

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Usefulness of Capsule Endoscopy in Children with Suspected Small Bowel Disease: Hae Jin Park, M.D., So Yeon Lee, M.D., Jae Sung Ko, M.D. and Jeong Kee Seo, M.D.; Korean J Gastrointest Endosc 2009;39(6):346-351. Published online December 30, 2009

Abstract PDF: Background
/Aims: The aim of our study is to investigate the diagnostic value and safety of capsule endoscopy (CE) in the pediatric patients with small bowel (SB) disease.
Methods
We retrospectively reviewed the records of 29 children (mean age: 11.8 year) who underwent CE at Seoul National University Children's Hospital between November 2004 and April 2009.
Results
Six (20%) of the total 29 patients could not swallow the capsule (mean age: 10.5 years), so the capsule was endoscopically placed into the stomach of these 6 patients. The CE examination for the entire SB was finished in 89.6% of the patients. The indications for CE studies were obscure gastrointestinal bleeding (OGIB) or anemia in 14 patients, intestinal polyposis in 8, abdominal pain in 4 and Crohn's disease in 3. The diagnostic yield of CE was 35.7% for OGIB or anemia, 37.5% for intestinal polyposis, 25% for abdominal pain and 33.3% for Crohn's disease. One patient had capsule retention during our CE investigations.
Conclusions
CE is a safe and valuable tool for the detection of SB Crohn's disease, the focus of OGIB and the presence of SB polyps in pediatric patients. (Korean J Gastrointest Endosc 2009;39:346-351)

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A Patient with Jejunal Mucinous Adenocarcinoma Metastatic to the Stomach Presenting with Submucosal Tumors in the Stomach and Jejunum: Gwang Sil Kim, M.D., Tae Joo Jeon, M.D., Tae-Hoon Oh, M.D., Won Chang Shin, M.D., Won-Choong Choi, M.D., Eunah Shin, M.D.*, Jung Yeon Kim, M.D.* and Hong-Joo Kim, M.D.^†; Korean J Gastrointest Endosc 2008;37(3):192-197. Published online September 30, 2008

Abstract PDF: The small bowel is the least common site for cancer to arise. Only approximately 1% of all gastrointestinal neoplasms arise in the small bowel. Mucinous adenocarcinoma is diagnosed when the amount of extracellular mucin in a tumor is over 50%. Because it is a very rare disease, there is little data available concerning its incidence, most common site of origin, and common sites of metastasis. There are no case reports describing primary mucinous adenocarcinoma of the jejunum in Korea. We report a case of jejunal mucinous adenocarcinoma metastatic to the stomach presenting as a submucosal tumor. (Korean J Gastrointest Endosc 2008;37:192-197)

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Diagnostic and Therapeutic Usefulness of Double Balloon Enteroscopy: Single Center Experience: Soo Hoon Eun, M.D., Jin-Oh Kim, M.D., Bong Min Ko, M.D., Keun Hyok Cho, M.D., Kyu Sung Chung, M.D., Joo Young Cho, M.D., Joon Seong Lee, M.D., Moon Sung Lee, M.D., Chan Sup Shim, M.D. and Boo Sung Kim, M.D.; Korean J Gastrointest Endosc 2008;36(2):64-70. Published online February 27, 2008

Abstract PDF: Background
/Aims: Until recently, only indirect procedures were available to provide images of the small bowel. Double-balloon enteroscopy (DBE) has the ability to obtain tissue for diagnosis and endoscopic interventions. This study was designed to determine the usefulness of DBE in patients with small bowel diseases by evaluating diagnostic yields and the impact on treatment. Methods: From November, 2004 to November, 2006 a total 81 patients with suspected small bowel disease were investigated by DBE. We analyzed the diagnostics and therapeutics rates according to the indications of DBE. Results: A total of 114 DBE procedures were performed. Gastrointestinal bleeding (64.2%) was the most common indication, followed by chronic abdominal pain/diarrhea (29.6%). A diagnosis was obtained in 44 of 52 patients with gastrointestinal bleeding and 17 of 24 patients with chronic abdominal pain/diarrhea. DBE resulted in therapeutic intervention in 17 patients with gastrointestinal bleeding and 13 patients with chronic abdominal pain/ diarrhea. DBE was diagnostic in 75.3% of the patients and played a role in the subsequent treatment of 37.0% of the patients. Conclusions: DBE was a useful and safe method for diagnosis and treatments in patients with small bowel diseases. (Korean J Gastrointest Endosc 2008;36: 64-70)

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A Case of Capsule Endoscopy in a 42-month-old Girl: Kyung-Jo Kim, M.D., Kyung Mo Kim, M.D.*, Sung Chul Kim, M.D.^†, Young Mi Cho, M.D.^‡ and Eun Jin Rho, M.D.^§; Korean J Gastrointest Endosc 2008;36(2):92-96. Published online February 27, 2008

Abstract PDF: Capsule endoscopy (CE) provides a minimally invasive examination of the entire small intestine, and is the preferred procedure for evaluation of patients with GI bleeding of unknown origin. Even though the FDA approved its use for pediatric patients between 10 and 18 years old in January 2004, little information is available regarding the effectiveness of CE in the younger pediatric population (below 6 years old) because of safety issues. A 42-month child with recurrent melena was referred to evaluate the cause of gastrointestinal bleeding. Despite extensive evaluation, including EGD, colonoscopy, a small bowel series, and Meckel's scan, the bleeding source was not identified. Finally, wireless CE demonstrated angiodysplasia on the mucosa of proximal jejunum. This is the first pediatric case of endoscopy-assisted CE under intravenous sedation without endotracheal intubation in Korea. (Korean J Gastrointest Endosc 2008;36:92-96)

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A Case of Small Bowel Obstruction due to a Mushroom Bezoar: Song Yi Kim, M.D., Jae Woo Kim, M.D., Jin Hon Hong, M.D., Ki Won Jo, M.D., Hong Jun Park, M.D., Il Young Lee, M.D., Chang Jin Yea, M.D., Hyun Soo Kim, M.D.,Soon Koo Baik, M.D. and Mee Yon Cho, M.D.*; Korean J Gastrointest Endosc 2007;35(6):410-414. Published online December 30, 2007

Abstract PDF: A mushroom bezoar is an unusual type of bezoar and a rare cause of small bowel obstruction, with the only cases being previously described in the foreign literature. Common sites of obstruction are the gastric outlet, the terminal ileum as well as segments of pre-existing gastrointestinal stenosis of various etiologies. Predisposing factors include a high fiber intake, inadequate chewing, gastric hyposecretion and hypomotility, and a previous gastrectomy and vagotomy. Computed tomography has the capability of directly showing the bezoar and displaying the resulting small bowel obstruction. We report a case of incomplete small bowel obstruction in a 38-year-old woman, caused by a mushroom bezoar in the terminal ileum. (Korean J Gastrointest Endosc 2007;35:410-414)

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