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Consensus Report
the 5th International Conference on Capsule Endoscopy™
Conference Chairs
Blair S. Lewis
Roberto de Franchis
Gèrard Gay
ICCE 2006

Two clinical congresses in 2006
Boca Raton, Florida, USA
 March 6-7, 2006
Paris, France
 June 9-10, 2006

Combined statistics
622 attendees
40 countries represented
146 abstracts presented
89 oral presentations
Consensus Activities
 Reviewed
last year’s data and updated
ICCE 2005 Consensus
 Drafted paper for peer-reviewed
publication in Endoscopy this fall
 Consensus Topics
IBD
Esophagus
Tumors
Bleeding
Celiac
Preps/Prokinetics
Inflammatory Bowel Disease (IBD)
June 2006
Panel Co-Chairmen
E. Seidman
I. Bjarnason
Panel Members: J. Leighton, P. Legnani, M. Gassull, J.F. Columbel, V.
Manoury, A. Kornbluth
IBD Consensus
Capsule Endoscopy (CE) for IBD:

Higher sensitivity for assessing small
bowel mucosal lesions compared to
other imaging techniques
Meta-analysis of Prospective
Comparative Crohn’s Disease
Studies: CE vs. Other Modalities
Published Study
n
Established or
Suspected
Costamagna 2002
3
Established/Suspected
Heigh 2003
17
Established
Bloom 2003
19
Established/Suspected
Buchman 2003
23
Established
Goelder 2003
5
Established
Voderholzer 2003
8
Established
Chong 2003
21
Established/Suspected
Eliakim 2004
35
Suspected
Toth 2004
47
Established/Suspected
Dubcenco 2004
31
Established/Suspected
Marmo 2004
19
Established
Triester et al Am J Gastroenterol 2006;101:954-964
11 studies,
n=223
CE vs.
SB Radiography
:
:
Study
IY (random)
95% CI
Incremental Yield (random)
95% CI
Costamagna 2002
Bloom 2003
Chong 2003
Heigh 2003
Buchman 2004
Dubcenco 2004
Eliakim 2004
Marmo 2004
Toth 2004
0.33 [-0.42, 1.09]
0.37 [0.08, 0.66]
0.48 [0.22, 0.73]
0.47 [0.17, 0.77]
0.00 [-0.27, 0.27]
0.61 [0.42, 0.81]
0.54 [0.35, 0.74]
0.53 [0.26, 0.80]
0.34 [0.17, 0.51]
Total (95% CI)
0.42 [0.30, 0.54]
Total yield: 66% (CE), 24% (SB radio)
Test for heterogeneity: P = 0.03, I² = 52.1%
Test for overall effect: P < 0.00001
-1
-0.5
Higher yield SB radiography
0
0.5
1
Higher yield CE
Triester et al Am J Gastroenterol 2006;101:954-964
CE vs. Ileoscopy
Study
IY (fixed)
95% CI
IY (fixed)
95% CI
Bloom 2003
Heigh 2003
Dubcenco 2004
Toth 2004
0.05 [-0.26, 0.37]
0.06 [-0.26, 0.37]
0.32 [0.09, 0.55]
0.11 [-0.09, 0.30]
Total (95% CI)
Total yield: 61% (CE), 46% (Ileoscopy)
Test for heterogeneity: P = 0.38, I² = 2.1%
Test for overall effect: P = 0.02
0.15 [0.02, 0.27]
-1
-0.5
Higher yield Ileoscopy
0
0.5
1
Higher yield CE
Triester et al Am J Gastroenterol 2006;101:954-964
CE vs. CT Enterography (CTE)
Study
IY (fixed)
95% CI
IY (fixed)
95% CI
Heigh 2003
Voderholzer 2003
Eliakim 2004
0.18 [-0.14, 0.50]
0.00 [-0.42, 0.42]
0.57 [0.38, 0.76]
Total (95% CI)
Total yield: 75% (CE), 37% (CTE)
Test for heterogeneity: P = 0.01, I² = 76.2%
Test for overall effect: P < 0.00001
0.38 [0.23, 0.54]
-1
-0.5
Higher yield CTE
0
0.5
1
Higher yield CE
Triester et al. Am J Gastroenterol 2006;101:954-964
Summary of Incremental
Yield (IY) of CE Over Other
Modalities
Total
yield
CE (%)
Total yield
other
modality (%)
% IY for CE
(95% CI)
vs. SB Radiography
66
24
42 (0.30-0.54)
vs. Ileoscopy
61
46
15 (0.02-0.27)
vs. CT Enterography
75
37
38 (0.23-0.54)
vs. Push Enteroscopy
51
7
44 (0.31-0.57)
vs. Small Bowel MRI
60
40
20 (0.41-0.81)
Triester et al. Am J Gastroenterol 2006;101:954-964
CE vs. Barium Radiography
Suspected CD subgroup
Study
IY (random) [95% CI]
IY (random) [95% CI]
0.00 [-0.85, 0.85]
0.38 [-0.04, 0.79]
0.54 [0.35, 0.74]
0.17 [-0.02, 0.37]
0.00 [-0.11, 0.11]
0.25 [-0.16, 0.66]
Costamagna 2002
Dubcenco 2004
Eliakim 2004
Toth 2004
Chong 2005
Hara 2005
Total (95% CI)
0.24 [-0.03, 0.51]
Total yield (fixed): 43% (CE), 13% (barium radiography)
Test for heterogeneity: P < 0.001, I² = 85.6%
Test for overall effect: P = 0.09
-1
-0.5
0
Yield higher in barium radiography
0.5
1
Yield higher in capsule endoscopy
Established CD subgroup
Study
IY (random) [95% CI]
IY (random) [95% CI]
0.50 [-0.21, 1.21]
0.03 [-0.20, 0.27]
0.70 [0.49, 0.90]
0.45 [0.23, 0.67]
0.61 [0.35, 0.87]
0.62 [0.38, 0.86]
0.67 [0.34, 0.99]
Costamagna 2002
Buchman 2004
Dubcenco 2004
Marmo 2004
Toth 2004
Chong 2005
Hara 2005
Total (95% CI)
0.51 [0.31, 0.70]
Total yield (fixed): 78% (CE), 32% (barium radiography)
Test for heterogeneity: P = 0.001, I² = 72.9%
Test for overall effect: P < 0.001
-1
-0.5
0
Yield higher in barium radiography
0.5
1
Yield higher in capsule endoscopy
CE vs. CT Enterography (n=58 pts)
CE detects more proximal disease
+ exams
Voderholzer et al. Gut 2005;54:369-373
Hara et al. Radiology 2006;238(1):128-134
MR Enteroclysis (n=18 pts)
+ exams
Golder et al. Int’l J of Colorectal Disease 2006;21(2):97-104
IBD Consensus
Capsule endoscopy (CE) vs. other imaging:

Limitations
 The available data are more evidence based for known,
non-stricturing CD than for suspected CD.
 No “gold standard” available for CD.
 CE is superior to CT enterography & MRI; particularly for
proximal - mid small bowel CD.
 CE demonstrates mucosal lesions missed by other
imaging.
 No single test is available for diagnosing CD.
IBD Consensus
CE may be useful in the study of
indeterminate colitis:
22 pts with colonic IBD underwent CE.
9 (40%) with “colitis” were found to have small
bowel lesions.
27 pts with IC underwent CE.
8 (29%) had small bowel lesions.
10 pts with IC underwent CE.
4 (40%) had small bowel lesions.
Mow WS, et al. CGH 2004;2:31-40
Mascarenhas-Saraiva M, et al. ICCE 2005 AB 115
Hume G, et al. ICCE 2004 AB 1054
IBD Consensus

31 patients with IC and known serology
 CE and serology equally sensitive (61%).
 CE was more sensitive than ASCA or OMP-C in
diagnosing small bowel CD.

Conclusion: CE was superior to CD-like markers
in identifying small bowel disease in IC patients.
Lo SK, et al., Gastrointest Endosc 2003;57(5):AB 1889
IBD Consensus
Role of CE in assessing for early postoperative recurrence



32 post-op ileocecal resection
CE & ileo-colonoscopy < 6 months
Recurrence: 21/32 – sensitivity
Ileo-colonoscopy 90% vs. 62% for CE
CE identified more proximal disease in 2/3 of cases.
CE may be useful as a first line evaluation of postoperative recurrence due to its good tolerability.
Bourreille et al Gut 2006;55:978-983
IBD Consensus
Role of CE in assessing for early
post-operative recurrence






14 patients post-op ileocecal resection x 1 yr
CE & small bowel US compared in 13 (1 stricture)
Recurrence: 12/13 by colonoscopy
US: 13/13 ( 1 false +)
CE: 12/13 (all true +)
CE represents an alternative minimally-invasive
technique for assessing CD recurrence in patients
under follow-up of ileo-colonic resection.
Biancone et al; Gastroenterology 2006;130(4):Supp S2: AB S1336
IBD Consensus
Capsule endoscopy (CE) for suspected IBD:

Useful and safe in patients with suspected
Crohn’s disease and negative endoscopic & small
bowel imaging
 Evidence: based mainly on retrospective studies;
more prospective data needed.
 Positive CE findings not well defined (lack of
validated scoring index).
 Has potential to affect patient management.
 Scoring index may provide diagnostic threshold.
Capsule Endoscopy:
Are All Ulcers Crohn’s?
A
B
C
Which image is an ulcer from Crohn’s
disease?
The answer is all three. However, patient history will define if
another cause, such as NSAID damage or radiation enteropathy
IBD Consensus

Standardized CE scoring index of disease severity
to differentiate normal from small bowel
inflammatory disorders in development.
Correlation of CE index with clinical disease activity
scores needed.
CE scoring index may not distinguish between various
causes of inflammation (NSAIDs, radiation enteropathy).
Scoring Index
 Parameters
Villous Appearance
Ulceration
Stenosis
Scale
Normal, edematous
Number - single, few, multiple
Distribution - localized, patchy,
diffuse
Longitudinal extent - short, long,
whole segment
Ulcer size - based on amount of
bowel wall circumference
involved
Stenosis - ulcerated or not,
traversed or not
Example of Score Template
Parameters
Villous Appearance
Ulcer
Number
Normal
Edematous
None
Single
Few
Multiple
Longitudinal Extent (%
of CE passage for
tertile)
Descriptors
Short Segment
Long Segment
Whole tertile
Short Segment
Long Segment
Whole tertile
Single
Patchy
Diffuse
<1/4
1/4-1/2
>1/2
(Score the largest ulcer)
Ulcerated
Non-Ulcerated
Traversed
Not traversed
Stenosis - Rate for
Whole Study
Stenosis
None
Single
Multiple
Global Disease Assessment: Normal, Mild, Moderate/Severe
Suspected Crohn’s Disease
Patients with characteristic GI symptoms of CD (at least 1 from “A”),
and with at least one of the criteria under “B”, “C” or “D”:
Characteristic GI Symptoms (anti-tTG negative)
Chronic abdominal pain
Chronic diarrhea
Significant weight loss
Growth failure
Extra-intestinal Symptoms
Unexplained recurrent fever
Arthritis/arthralgias
Pyoderma/erythema nodosum
Aphthous stomatitis
Perianal disease
PSC/recurrent cholangitis
Inflammatory Markers
Iron deficiency anemia
Thrombocytosis or leukocytosis
Elevated ESR or CRP
Hypoalbuminemia
Positive IBD serology
Fecal markers: lactoferrin, alpha-1 antitrypsin, calprotectin; heme +; leucocyte +
Abnormal, Non-diagnostic Imaging
Suspected SB CD
Positive
ileocolonoscopy
Negative ileocolonoscopy
or unsuccessful
No
obstruction
Possible or known
obstruction
Patency
capsule
No obstruction
Capsule
endoscopy
either/or
Obstruction
CTE/MRE
(SBFT)
Presence of SBCD
Treat accordingly
Figure 1. Algorithm for the approach to suspected small bowel Crohn’s Disease (CD). The absence of any mucosal lesions demonstrated by a complete
assessment of the small bowel by capsule endoscopy excludes active CD of the small bowel. Patients with symptoms suggestive of obstruction, or known to
have a stenosis should either undergo a patency capsule exam or evaluation by CTE or MRE prior to capsule endoscopy.
Abbreviations: SB CD=small bowel Crohn’s Disease, CTE=CT enterography, MRE=MR enterography, SBFT=small bowel follow through.
Capsule Retention and CD
Author Type
Patients (n)
Capsule
Retention (%)
Type
Mow
50
4
Known
Herrerias
21
0
Suspected
Fireman
17
0
Suspected
Eliakim
20
0
Suspected
Sant’Anna
20
5
Suspected
Buchman
30
6.7
Known
Chiefetz
38
13.0
Known strictures
Capsule Retention in
Crohn’s Disease


In patients with Established CD, the risk is
5%, despite absence of strictures on SBFT.
In cases with Suspected CD:
 The risk is low with negative SBFT.
 If no SBFT, in the absence of obstructive symptoms, risk
is yet unknown.
Conclusions

CE has a higher sensitivity for assessing small bowel
mucosal lesions compared to other imaging techniques.
 CE is helpful diagnosing suspected Crohn’s in the
pediatric population.
 CE is superior to CT enterography & MRI; particularly for
proximal - mid small bowel CD.
 CE may be useful as a first line evaluation of
postoperative recurrence of CD.
 CE can detect small bowel lesions in a significant number
of patients with indeterminate colitis and may alter disease
management.
 CE is useful and safe in patients with suspected Crohn’s
disease and negative endoscopic & small bowel imaging.
Esophagus
June 2006
Panel Co-Chairmen
R. Eliakim
G. Eisen
Panel Members: J.P. Galmiche, T. Roesch, F. Schnoll-Sussman,
J. Herrerias, V.K. Sharma, E. Coron
Consensus Statement Esophageal Capsule
Endoscopy (ECE)
 A new
approach to
esophageal diagnostics
Simple and easy
Patient-friendly
Screening tool for esophageal
diseases
Encouraging initial clinical data
Esophageal Varices
Barrett’s Esophagus
Consensus Statement –
Varices

Esophageal varices (EV) are a serious consequence of
portal hypertension (PHT).
 In patients with cirrhosis, the incidence of EV increases
5% per year and the rate of progression from small to
large varices is 5-10%.
 Increasing size of varices is associated with increased
wall tension leading to rupture and bleeding.
 AASLD/UK guidelines recommend endoscopic
screening of patients with cirrhosis for varices and
treatment of patients with medium/large varices to
prevent bleeding.
Eisen G, De Franchis R, Eliakim R, Zaman A, Schwartz J, Faigel D, Rondonotti E, Villa F, Weizman E, Yassin K.
Preliminary results of International Multicenter Trial. 32 patients reported. ICCE 2006 AB 20154
Consensus Statement –
Varices (continued)




Recommended endoscopic screening intervals are
1-3 years, depending on presence/absence of varices
and whether patient has
compensated/decompensated liver disease.
Endoscopic surveillance is performed in patients after
obliteration of varices.
This patient population could benefit from a noninvasive diagnostic test that does not require
sedation.
These recommendations/practices represent a
potentially large endoscopic burden.
Eisen G, De Franchis R, Eliakim R, Zaman A, Schwartz J, Faigel D, Rondonotti E, Villa F, Weizman E, Yassin K.
Preliminary results of International Multicenter Trial. 32 patients reported. ICCE 2006 AB 20154
EV Screening Pilot Trial
 Initial pilot trial – EV screening with ESO
 Prospective blinded, 3 center study
 32 patients – enriched population with surveillance
 No complications, no retention
 Japanese endoscopic grading system
F0 = none
F1 = small
F2 = medium
F3 = large
 Modified classification for current trial
None/small/medium-large
Medium-Large > 25% circumference
Eisen G, Eliakim R, Zaman A, Schwartz J,Faigel D, Rondonotti E, Villa F, Weizman E, Yassin
K, de Franchis R. Endoscopy 2006:38:1-5
Comparison of PillCam ESO
and EGD: Esophageal Varices
Reference
# Patients
Study
Design
Sensitivity
Specificity
PPV
NPV
Study 1
21
Prospective
Blinded
81%
100%
100%
57%
Study 2
97
Prospective
Blinded
87%
87%
94%
74%
Study 3
32
Prospective
Blinded
100%
89%
96%
100%
1.Lapalus
MG. Endoscopy 2006;38:36-4
2.
Eisen GM, de Franchis R. Interim Analysis of the Evaluation of PillCam ESO in the Detection of Esophageal Varices AB
20154
3.Eisen
G, de Franchis R, Eliakim R, Zaman A, Schwartz J, Faigel D, Rondonotti E, Villa F, Weizman E, Yassin K,
Endoscopy 2006;38(1):1-5
Esophageal Image Spectrum
Barrett’s Esophagus
Epidemiology
in Barrett’s Esophagus
7% of US Population have
daily GERD Symptoms
10% of Chronic GERD Patients
have Barrett’s esophagus
Risk of esophageal cancer in Barrett’s esophagus
30-60 times > general population
up to 2% of patients with BE
Locke III et al. Gastro 1997: 112:1448-1456.
Falk GW. Gastro Endosc 1999; 49(3):S29-34.
Screening for
Barrett’s Esophagus

Adenocarcinoma is a lethal disease.
 GERD is a firmly established risk factor for this
cancer.
 Barrett’s esophagus, a premalignant precursor, is
firmly associated with GERD symptoms, and is
clearly associated with an increased risk of cancer
(RR 30-60 X general population).
Multi-center Study Overview
 Primary aims
 Accuracy of ECE compared with EGD for the diagnosis of esophageal pathology
in patients with chronic GERD symptoms
 Specificity, sensitivity, PPV, NPV
 Safety and adverse events of ECE
 Secondary aims
 Assess capability of ECE to identify presence of Barrett’s esophagus in patients
undergoing surveillance endoscopy
 Assess patient satisfaction with both procedures
 Multi-site: Prospective 7-center international study
 Israel (3), USA (3), Germany (1)
 Inclusion criteria
 Aged 18 years or older
 Confirmation of 1 of the following:
 Histologic confirmation of Barrett's esophagus undergoing surveillance endoscopy
 Chronic GERD symptoms undergoing upper endoscopy for the evaluation of GERD
Eliakim R et al. J Clin Gastroenterol 2005;39:572-578
Patient Enrollment
109 patients enrolled
1 unable to swallow capsule
2 technical difficulties
106 included in per-protocol statistical analysis
93 (88%) endoscoped for
GERD symptoms
13 (12%) for surveillance of
Barrett’s esophagus
Eliakim R et al. J Clin Gastroenterol 2005;39:572-578
Methods

ECE swallowed using standardized
ingestion protocol.

Blinded investigator reviewed ECE videos.

Upper endoscopy performed on the same day
following ECE.

Adjudication committee arbitrated if discrepancy
between procedures was noted.

Barrett’s cases were not biopsied for confirmation.
Eliakim R et al. J Clin Gastroenterol 2005;39:572-578
Multi-center Study Results:
Esophagitis
EGD
ECE
+
-
+
33
1
-
4
68
ECE
Sensitivity
89%
Specificity
99%
Positive Predictive Value (PPV)
97%
Negative Predictive Value (NPV)
Adjudicated results
94%
Eliakim R, Sharma VK et al. In press. J Clin Gastro
Multi-center Results:
Barrett’s Esophagus
EGD
ECE
+
-
+
-
32
1
1
72
Sensitivity
Specificity
Positive Predictive Value (PPV)
Negative Predictive Value (NPV)
Adjudicated results
ECE
97%
99%
97%
99%
Eliakim R, Sharma VK et al. In press. J Clin Gastro
ECE Clinical Trials
Barrett’s Esophagus
Feasibility Trial
3rd ESO Trial
# of Patients
17
42
Investigators
Eliakim, Yassin,
Shlomi, Suissa,
Eisen
Koslowsky, Jacob,
Eliakim, Adler
Adjudication
Panel
no
no
Sensitivity
100%
100%
Specificity
80%
100%
Publication
APT 2004;20:1-7
Endoscopy 2006;38
(1):27-30
ECE Clinical Trial Data:
Barrett’s Esophagus
Reference
VA Mason Trial
Kansas Trial
2
1
# Patients
Sensitivity
Specificity
PPV
NPV
58
67%
84%
56%
89%
32
73%
86%
86%
74%
1.Lin
et al. Blinded Comparison of Esophageal Capsule Endoscopy vs. Conventional Endoscopy for Diagnosis of Barrett’s
Esophagus in Patients with Chronic Gastroesophageal Reflux GIE ( in Press)
2.Sharma
et al Gastroenterology 2006;130(4) April AB S1812
Conclusions

ECE does offer a minimally invasive method to
screen for esophageal varices and portal
hypertensive gastropathy.
 ECE does have a role in the evaluation of patients
with esophageal disease that would otherwise
avoid traditional testing methods.
 Large scale studies are needed to confirm
outcomes.
GI Bleeding
June 2006
Panel Co-Chairmen
M. Pennazio
I. Gralnek
Panel Members: M. Delvaux, N. Reddy S. Bar Meir,
Demedts, M. Keuchel
I.
Panel Participants
(Boca Raton/Paris)
Martin Keuchel
Ingrid Demedts
Simon Bar-Meir
Nageshwar Reddy
Michael Delvaux
Scott Ketover
Morry Moskovitz
Shenan Abey
Colm O’Morain
Value of CE for
Obscure GI Bleeding

CE is a valuable diagnostic modality in evaluating
obscure GI bleeding.
 Key advantages of CE include: ability to image
entire small bowel; ability to review and share
images; patient preference; safety profile; ability to
conduct in variety of settings; clarity of image
comparable to other endoscopy.
 2 meta-analyses support role of CE in OGIB*.
*Triester et al. Am J Gastro 2005;100:2407-2418
*Marmo et al. APT 2005;22:595-604
Value of CE for
Obscure GI Bleeding
Marmo et al. APT 2005;22:595-604
Value of CE for
Obscure GI Bleeding
Triester et al. Am J Gastroenterol 2005;100:2407-2418
Accuracy of Diagnostic
Interpretation
Study
Pennazio et al.
Sensitivity
(%)
Specificity
(%)
PPV
(%)
NPV
(%)
88.9
95
97
82.6
Gastrpenterology 2004
Delvaux et al.
94.4 100
Endoscopy 2004
Saurin et al.
92
48
95
75
95.2
98
96.1 97.6
100
87
87.9 100
Endoscopy 2005
Hartmann et al.
95
86
GIE 2005
Hindryckx et al.
ICCE 2006
Walsh et al.
DDW 2006
Algorithm for CE in
Obscure GI Bleeding
 Add
algorithm OGIB
Pennazio M, Eisen G, Goldfarb N.
ICCE Consensus - Endoscopy 2005
“Missed Lesions” Detected
by CE

Selby W. et al. GIE 2005;61(5): AB M1390
 Chung H. et al. DDW 2006;63(4) Supp S: AB
M1247
 Edery J. et al. ICCE 2006;AB 366470
7% to 25% of lesions detected by CE
are NOT in the small bowel.
Clinical significance unknown.
“Early CE” in Overt OGIB

Ben Soussan et al. ICCE 2006;AB 366874
 Gay G. et al. ICCE 2006;AB 367198
Yield of CE: 70-84%
Timing of CE is important.
Patient Selection for CE in
Obscure GI Bleeding

Patient selection for CE in OGIB is established in
the literature; yet for IDA it is not.

Clinical parameters to predict diagnostic yield not
clearly established: transfusion requirements.
May A. et al. J Clin Gastro 2005;39:684-688
Al Ali J. et al. Gastrointest Endosc 2006;63(4): AB M1346
Capsule Endoscopy and
Double-balloon Enteroscopy
“An initial diagnostic imaging employing CE might be
followed by DBE for treatment or histopathological
diagnosis.”
Nakamura M, et al. Endoscopy 2006;38(1):59-66
Hadithi M, et al. Am J Gastro 2006;101:52-57
“The use of CE as a filter for DBE results in effective
management of patients with various intestinal diseases.
CE can also direct the choice of route of DBE.”
Gay G, et al. Endoscopy 2006;38(1):49-58
Pennazio M. et al. DDW 2006;63(4) Supp S AB 496
Re-bleeding Rates in Patients
with Positive and Negative CE
49 OGIB patients
 Yield of CE: 31 (63%)
 Interventions: 15 (30.6%)
 Mean follow-up: 19 m.
 Re-bleeding rate: 32.7%
 CE -: 5.6%
p=0.03
 CE +: 48.4%
Lai L, et al. Am J Gastro 2006;101:1224-1228
Longitudinal Prospective
Cohort Study
 285 OGIB patients
 Yield of CE: 177 (62%) – 50% underwent treatment
 Re-bleeding rate: 44 (18%)
FACTOR
RR for bleeding relapse
Diagnosis “angioectasia”
Age >60 yrs.
Use of anticoagulants
6.64
2.87
2.65
Prior bleeding events
Negative CE
2.90
0.54
Albert JG, et al. DDW 2006;130(4): AB T1108
Repeating CE

Bar-Meir S. et al. GIE 2004;60:711-13
 Jones B.H. et al. Am J Gastro 2005;100:58-64
 Dhaliwal H. et al. Gastrointest. Endosc.
2006;63(4) Supp S: AB M1247
 Kimble JS. et al. Gastrointest. Endosc. 2006;63(4)
Supp S:AB 497
Role of Repeat CE in Obscure
GI Bleeding and IDA

Repeat upper endoscopy for OGIB has a 10-26%
diagnostic yield. GI mucosal disease is a dynamic
process and bleeding lesions may be present
intermittently1.
 If initial study is non-diagnostic, repeat CE may
increase diagnostic yield
 If initial CE study is technically inadequate (poor
visualization, not reaching colon) repeat exam.
 Prospective comparative studies with other
diagnostic modalities are needed.
1.
Am J Gastroenterol 2005;100:1058-64
Impact of CE on Patient Management
and Outcomes in Obscure GI Bleeding
Follow-up Studies Assessing the
Influence on Clinical Outcome of
Capsule Diagnosis in Patients with OGIB
Study
Year
Pts
(n)
Yield of CE
(%)
Mean
follow-up
Influence on
clinical outcome
Pennazio et al.
2004
100
47
18a
+
Delvaux et al.
2004
44
61
12
+
Carey et al.
2004
260
58
6.7
+
Favre et al.
2004
50
50
11
+
Chong et al.
2004
75
69
4.7
+
Rastogi et al.
2004
43
42
6.7
-
De Leusse et al.
2005
64
45
13b
+
Neu et al.
2005
56
68
13
+
Walsh et al.
2005
100
66
21
+
Kinzel et al.
2005
47
74
12
+
De Looze et al.
2005
45
53
12
+
Albert et al.
2005
278
62
20c
+
Viazis et al.
2005
96
42
14d
+
Saurin et al.
2005
56
71
12
+/-
Pennazio M. GIE Clin N Am 2006; 16: 251-66
Major Management Changes
and Outcomes in Relation to
Diagnostic Findings
PATIENTS WITH FINDINGS
ON CAPSULE ENDOSCOPY
n
Management
change
No further
bleeding
Reduction of
bleeding by > 50%
Tumors, erosions, ulcers
(due to Crohn's, NSAID, etc.)
11
9 (82%)
6 (55%)
7 (64%)
Angiodysplasia, bleeding
27
8 (30%)
15 (56%)
21 (78%)
Negative
18
4 (22%)
14 (78%)
16 (89%)
PATIENTS WITH FINDINGS
ON OTHER TESTS
n
Management
change
No further
bleeding
Reduction of
bleeding by > 50%
Tumors, erosions, ulcers
(due to Crohn's, NSAID, etc.)
4
4 (100%)
2 (50%)
3 (75%)
Angiodysplasia, bleeding
17
7 (41%)
5 (29%)
12 (71%)
Negative
35
10 (29%)
28 (80%)
29 (83%)
Major management and outcome changes were mainly
in the groups with other than vascular lesions and of negative cases.
Neu B, et al. Am J Gastro 2005;100:1736-1742:
Impact of CE on Patient
Management and Outcomes
in Obscure GI Bleeding

Published studies support a role for CE in directing
patient management and improving outcomes.
 However, these studies lack standardized
treatment protocols for findings at CE.
 Additional prospective studies are needed to better
define the impact on patient outcomes in obscure
GI bleeding.
 Outcomes to be measured:
 Bleeding resolution
 Transfusion requirements
 HLOS
 Patient satisfaction and HRQOL
 Resource utilization (e.g., additional diagnostic studies)
Role of CE in Iron Deficiency
Anemia (IDA)

The World Health Organization estimates that approximately onethird of the population has IDA, yet it remains an under-managed
complication of numerous gastrointestinal conditions*.
 Despite undergoing standard endoscopic evaluation of IDA with
EGD and IC, up to 30% of patients with IDA remain without
diagnosis.
 CE allows evaluation of the entire small bowel, is significantly more
sensitive than radiographic examinations and standard endoscopy,
and has been shown to have high diagnostic yields in patients with
obscure GI bleeding and IDA*.
Apostolopoulos P, Liatsos C, Gralnek IM, et al. “The Role of Wireless Capsule Endoscopy in Investigating Unexplained •
Iron Deficiency Anemia After Negative Endoscopic Evaluation of the Upper and Lower Gastrointestinal Tract.” Endoscopy
2006 (in Press);
Isenberg G. et al. Gastrointest. Endos. 2006: 63(4);AB M1301
Milano A. et al. Gastrointest. Endos. 2006; 63(4):AB T1110
Iron Deficiency Anemia (IDA)
Algorithm
Unexplained IDA* [1,2]
Ileocolonoscopy
EGD + gastric + D2 biopsies**
NEGATIVE
Consider also:
age, symptoms
Video capsule endoscopy (VCE)
Negative
Treat with Fe and observe for 3 months; Consider
additional diagnostic studies (e.g., repeat VCE, push enteroscopy,
ileocolonoscopy) if no improvement or recurrent IDA [3]
Positive
Institute lesion-specific treatment
for clinically significant findings***
*IDA proposed definition: Hgb < 10-11.5 g/dl in women and < 12.5-13.8 g/dl for men, MCV <76, ferritin <15 ug/dl.
**Celiac serologies as clinically indicated. ***medical/surgical therapy, double-balloon enteroscopy, intraoperative enteroscopy.
[1] Fireman et al. Digestive and Liver Diseases 2004;36:97-102.
[2] Goddard et al. Gut 2000;46(suppl 4) 1-5.
[3] Bar-Meir et al. Gastrointest Endosc 2004;60:711-13.
Take-home Messages



Capsule endoscopy should be performed early in the
course of the work-up of patients with obscure bleeding
and IDA (algorithms).
Studies assessing the cost-effectiveness and budget
impact of different approaches are needed.
If initial study is non-diagnostic and bleeding continues,
repeat CE may increase diagnostic yield; prospective
comparative studies with other diagnostic modalities are
needed.
 A second CE may prove of value if the lesion responsible for bleeding
is bleeding intermittently or
 If the lesion was not seen on the initial exam (bowel unclean and
obscures lesion).
Jones H et al. Yield of Repeat Wireless Video Capsule Endoscopy in Patients with Obscure Gastrointestinal Bleeding.
Am J. Gastroenterol 2005;100:1058-64
Tumors
June 2006
Panel Co-Chairmen
G. Gay
W. Selby
Panel Members: J.S. Barkin, E. Toth, S. Lo, C. Fraser,
F. Hagenmueller, J.F. Rey
Small Bowel Tumors (SBT)

SB tumors account for: 3 - 6% of GI tumors
1 - 2% of GI malignancies

Yearly Incidence
 USA
1-1.4/100,000
 France
 Men: 0.5 – 1.3/100,000
 Women: 0.8/100,000

Malignant tumors of small bowel have a poor
prognosis
 Metastases
 Unresectable
 Survival rate
45% - 75%
20% - 50%
32.7% at 5 years
Clinical Presentation of SBT

Two clinical pictures
 Intestinal obstruction
 Obscure digestive bleeding

Often diagnosed late in course or incidentally at laparotomy
or biopsy.
 At least 50% of benign lesions remain asymptomatic.
 Approximately 80% of malignant lesions produce symptoms.
 Symptoms or signs are not specific for either benign or malignant
tumors.

Presentation depends on the pathology of the neoplasm
and location.
Morphological Investigations
for Intestinal Tumors
Radiology
Small bowel follow-through with enteroclysis
+
Abdominal ultrasound
+
CT scanner / MRI
++
CT scanner / MRI with enteroclysis
+++ (if tumor > 1cm)
Endoscopy
Push enteroscopy
++
Intra-operative enteroscopy
+++
Ileo-colonoscopy
++
Oesogastroduodenoscopy
+
Video capsule endoscopy (VCE)
+++
Push and pull enteroscopy
+++
Nuclear Medicine
Octreo-scan
Specific for neuroendocrine tumors
SB Tumors and PillCam CE
Frequency of Intestinal Tumors detected by VCE
# Patients
Number of
Tumors
% Malignant
Tumors
% with
Obscure
Bleeding
Corbin, 2004
562
50 (8.9%)
53 %
79 %
Delvaux, 2006
391
48 (12.3%)
61 %
70.8 %
Bailey, 2006
416
26 (6.3 %)
67 %
81 %
Urbain, 2006
433
11 (2.5 %)*
100 %

The most common indication for PillCam endoscopy in patients
with SBTs was obscure GI bleeding/anemia (80%).

PillCam endoscopy detected SBTs after patients had undergone an
average of 4.6 negative procedures
*Malignant tumors only
SB Tumors and PillCam CE

60% of SBT were malignant






adenocarcinoma
carcinoid
melanoma
lymphoma
sarcoma, GIST
40% of SBT were benign




GIST
hemangioma
hamartoma
adenoma
SB Tumor Consensus

Can we predict an increased likelihood of SBT in a
patient referred for VCE?
 presentation such as abdominal pain, weight loss, proteinlosing enteropathy
 physical findings – mass, ascites, etc.
 episode of small bowel obstruction
 history of previous tumor

The type of OGIB – occult or overt – is not helpful.

Sensitivity of clinical signs for SB tumor is low.
SB Tumor Consensus
 Procedures
available prior to VCE in patients
with suspected SBT
No role for SB follow-through with or without enteroclysis
CT ± enteroclysis
MRI ± enteroclysis
 In
the presence of obstructive signs can one
predict the risk of retention?
CT/MRI with enteroclysis
Patency capsule
SB Tumor Consensus
 Role
of VCE in diagnosing SB Tumours
VCE > PE
VCE ≈ PPE (DBE)
 Place
of VCE in the diagnostic process
Obscure GI bleeding
 Directly to VCE regardless of age
Obstructive-type symptoms
 Consider PPE (DBE)
SB Tumor Consensus

Can we reliably determine criteria to indicate the
presence of a mass lesion at endoscopy?
mucosal disruption
intact mucosa
 submucosal lesion
 extrinsic, e.g., intra-abdominal tumor
false positive: is any bulging a mass?
 intussusceptions
 external compression by normal abdominal organ
SB Tumor Consensus
What does a mass lesion found at VCE mean?
Pancreatic rest
GIST
SB Tumor Consensus
Can we predict histology/tumor type from VCE appearances?
adenocarcinoma
GIST
pancreatic carcinoma
SB Tumor Consensus
Proposed score for probability of “mass” lesions seen at VCE
MAJOR
MINOR
Bleeding Mucosal Irregular Polypoid
disruption surface appearance
Color
Delayed White Invagpassage villi ination
(≥ 30’)
++
++
++
++
++
++
++
++
Interme- +/diate
+
+
+
+
+
+
+
-
-
+/-
-
-
-
-
High
Low
-
These can be scored 3,2,1 to develop a tumor score.
SB Tumor Consensus
High probability
adenocarcinoma
GIST
adenocarcinoma
B-cell lymphoma
SB Tumor Consensus
Intermediate probability
adenoma
GIST
SB Tumor Consensus
Low probability
Normal at intraoperative
enteroscopy
heterotopic gastric
mucosa
SB Tumor Consensus

Proposal of a practical approach
Sequence of the procedures
Procedures needed to make a decision
Clinical relevance of the tumor score
SB Tumor Consensus
“Mass” at VCE
High or Intermediate Probability of a Tumor
Cross-sectional imaging  enteroclysis to assess
extraluminal disease
PE/DBE
Surgery
SB Tumor Consensus
“Mass” at VCE
Low probability of a tumor
Cross-sectional imaging  enteroclysis
Abnormal CT scan
High or Intermediate
PE/DBE
Surgery
Normal CT scan
Significant
clinical history
No significant
clinical history
PE/DBE
Repeat
VCE
SB Tumor Consensus

Key points of the consensus for diagnosis:
VCE leads to diagnosis of SB tumors earlier in their
course.
SB tumors detected with VCE are frequently revealed
by OGIB, whereas previously, the most common
presentation was obstruction and pain.
SB Tumor Consensus

Key points of the consensus for treatment
High or intermediate probability lesions may lead to
DBE or surgery.
The treatment of lesions with low probability will
depend on their clinical significance.
SB Tumor Consensus
 Some
unsolved issues
Does VCE lead to improved outcome of SB
tumors?
 Yes, if VCE leads to further diagnosis1
 Outcome research essential
Does VCE have a role in the follow-up and
surveillance of treated SB tumors?
 Not used at present
 It may have a role – possibly depending on the histological type of
tumor
 Need for further research
1.
Bailey AA, Debinski H, Appleyard M, Remedios M, Hooper J, Walsh A, Selby WS. Diagnosis and outcome of small bowel
tumors found by capsule endoscopy: a three-center Australian experience. Am J Gastroenterol 2006;101:In Press
SB Tumor Consensus
 Future
directions
Assessing outcomes after diagnosis of SB tumor by VCE
Assessing outcomes for polyposis syndromes
Predicting pathology and tumor type by VCE findings
Evaluating the tumor scale
Assessing size and location of lesions seen by VCE
Improving visualization of duodenal/periampullary lesions
Evaluating the role of VCE in specific tumors
Attempting to reduce the rate of false negative VCE
Celiac Disease
June 2006
Panel Co-Chairmen
C. Cellier
J. Murray
Panel Members: P. Collin, G. Costamagna, P.H.R. Green, G.R.
Corazza, E. Rondonotti, S. Schuppan, M. Willis
Panel Participants

Christophe Cellier
 Pekka Collin
 Peter Green
 Joe Murray
 Emanuele Rondonotti
 Moshe Rubin
 Detlef Schuppan
 Marsh Willis

Consensus Co-chairmen
 Roberto de Franchis
 Blair Lewis
 Gèrard Gay
Clinical Challenges
Celiac disease is an immune-mediated disorder
that primarily affects the GI tract. It is characterized
by chronic inflammation of the small intestine
mucosa that may result in atrophy of intestinal villi,
malabsorption, and a variety of clinical
manifestations, which may begin in either
childhood or adult life.
NIH Consensus 2004
Diagnosing Celiac Disease:
“Tip of the Iceberg” Concept
Typical forms
1:2000 population
Diarrhea
Abdominal pain
Weight loss/failure to thrive
NIH Consensus 2004
Diagnosing Celiac Disease:
“Tip of the Iceberg” Concept
Atypical forms1%
USA> 3 million population
Europe > 2 million population
Worldwide disease is more
severe than previously
indicated.
Diabetes, Anemia,
Osteoporosis, Irritable
Bowel Syndrome,
Malignant problems,
Neurological problems,
Behavioral changes
Mäki et al, NEJM 2003
NIH Consensus 2004
Background:
Diagnosis of Celiac Disease
 Villous atrophy (duodenum)
total/ subtotal
partial
increased number of IEL
 Circulating antibodies
anti-endomysial IgA
anti-transglutaminase IgA
sensitivity/specificity > 95%
 Response
(clinical
/histological) to a GFD
 HLA DQ2 or DQ8: difficult case
negative predictive value
(99%)
Consensus NIH 2004
Diagnosis of Celiac Disease






Symptoms mimicking
IBS (diarrhea, bloating,
abdominal pain, etc.)
Anemia (iron, folate,
B12)
Elevated transaminases
Osteoporosis
>60 years old (20%)
<18 years old (4.6% to
17%)
Consensus NIH 2004
De Franchis et al. Gastroenterology 2005;128;Supp 2:AB 548
Krauss et. al. Gastroenterology 2005;128:Supp 2:AB 547
Background:
Treatment of Celiac Disease
Gluten free diet (wheat,
rye, barley)
Poor observance
Malignant complications
Osteopenia
Auto-immune disorders
Consensus NIH 2004
Background:
Malignancy and Celiac Disease
 T- lymphoma:EATL
In adults 0.5-1 per million
people, covers 35% of all
small bowel lymphomas.
 Adenocarcinoma
Occurs in 0.6-0.7 per
100,000 general
population;13% of these
cases are associated with
celiac disease.
 Clonal refractory sprue
(CD3+/CD8-/CD103+):
ulcerative jejunitis
 Alarm symptoms:
obstruction, weight loss,
bleeding,pain, fever
Current Data Highlights:
Celiac Disease at diagnosis
 Capsule
and diagnosis of CD
de Franchis et al: ICCE2005: AB 015
Murray et al: Gastrointest Endosc 2003;58(1):92-95
Krauss et al: ICCE 2005:AB 049
n > 100 patients at diagnosis
Comparison of capsule findings and histology:
VCE equivalent to histology for the diagnosis of
severe atrophy.
 More
data required for patients with partial
villous atrophy.
Rondonotti et al :ICCE 2006;AB 20122
Current Data Highlights:
Celiac Disease Diagnosis

Mapping the extent of CD
Murray et al Gastrointest Endosc 2004;59(4) AB459
 Length of involvement: no correlation with GI symptoms,
correlation with osteopenia
Muhammad et al ICCE 2006 AB 20103
 CD in duodenum and proximal intestine may be entirely normal
while the distal intestine shows classic features of CD. Extent of
CD can be estimated by CE which is not possible by other
modalities.

Patients with positive serology and negative
histology
Adler et al ICCE 2004 AB 1022
 Patients with abdominal pain, positive celiac serology, and
negative biopsy may still have organic disease in the SB.
Current Data Highlights:
Complicated Celiac Disease

Screening for complicated celiac disease
Patients symptomatic on a GFD
Daly et al Gastrointest Endosc 2004;59(5) AB 1806
(n= 47):
villous atrophy: 68%
ulcerations 50%
cancer: 5%
Krauss et al. Gastroenterol 2005;128(4) AB:547
(n=43)
ulcerations: 25%
tumours: 5%
Proposed Algorithm:
Celiac Disease (CD) Diagnosis
CD diagnosis?
tTG EMAIgA +
tTG+
EMA+
Duodenal biopsies
Villous atrophy
GFD
Failure: CE
Normal architecture
CE?
CE?
?stop/evaluate
Proposed Algorithm:
Complicated Celiac Disease
Failure of GFD
GFD observance
yes
CE
Negative
Dietician
Positive
Observe
No
VA to dietician and
IEL phenotype
Tumor or UJ to DBE
Consensus on Celiac Disease
Symptomatic Treated CD
CE is frequently abnormal in symptomatic CD on a
gluten free diet.
Atrophy (60%)
Ulcers common (20 -50%)
significance (histological specimens)
mostly in clonal refractory sprue (type II)
Malignancies 2-10%
lymphoma
adenocarcinoma
Defining “Atrophy”

The presence of scalloping, fissuring, and
mosaic patterns is characteristic of villous atrophy.
 The lack of visualization of normal villi in several
successive folds alone might suggest CD.
 Minimal standard terminology and validation study
needed.
Celiac Image Spectrum
Absent Villi
Fissuring
Scalloping
Scalloping
Mosaic pattern
Fissuring and ulcer
Celiac Consensus Conclusions
Indications for CE for the diagnosis of
CD:
 High suspicion (tTg+, EmA+, or symptoms
etc) in patients unwilling or unable to undergo
upper GI endoscopy
 CE may be helpful when there is diagnostic
difficulty such as:
 Sero + (EMA or tTG) with negative histology
(patchy disease)
 Ambiguous histology and negative serology
Celiac Consensus Conclusions
Indications for CE in patients
with known CD:
 For alarm symptoms in patients on a strict
GFD (risk of malignancy)






Weight loss
Bleeding
Anemia
Pain
Fever
Recurrent malabsorption symptoms
 Abnormal imaging (except stricture)
Consensus on Celiac Disease:
Diagnosis

Celiac disease should be considered in every CE
examination for any reason (1% in general pop.).
 All CE endoscopists need to be able to recognize
features of CD.
 Standard terminology and inter-observer agreement
needed.
 There is supportive data for Positive Predictive
Value.
 Need more data for Negative Predictive Value
(partial villous atrophy).
Preps & Prokinetics
Panel Co-Chairmen
K Mergener
T Ponchon
Panel Members: R. Enns, H. Nuutinen, B. Filoche, I. Schmelkin,
D. DeMarco, W. Qureshi, D. Heresbach
Clinical Challenges
Limitations of capsule endoscopy in some
cases:

Dark/opaque intestinal contents, bubbles, food/medication
particles, fecal matter, impairing visualization of the
mucosa
Clinical Challenges
(continued)
Limitations of capsule endoscopy in some
cases:

Slow gastric emptying and/or small bowel transit, leading to
incomplete small bowel imaging in approximately 15-20%
of cases
ASGE CE SIG Survey
Do you routinely use a laxative prior to SB capsule exams?
100
90
80
70
60
50
40
30
20
10
0
Yes
No
ASGE CE SIG Survey
If “yes”, which laxative do you use?
35
30
25
20
15
10
5
0
PEG 0-2L
PEG > 2L
PSoda
Other
ASGE CE SIG Survey
Do you routinely use a prokinetic agent prior to SB CE?
90
80
70
60
50
40
30
20
10
0
Yes
No
ASGE CE SIG Survey
If “yes”, which type of prokinetic agent do you use?
50
45
40
35
30
25
20
15
10
5
0
Tegaserod
Metoclopramide
Erythromycin
Definitions

Bowel preparations: Medications given with the
primary aim of cleansing the small bowel.

Prokinetics: Medications given with the aim of
accelerating gastric emptying and/or small bowel
transit times, thus improving the proportion of
cases in which the colon is reached.
Preps & Prokinetics
2006 Consensus Questions
1. Has a scale been validated to evaluate SB cleanliness?
2. Do preps affect SB cleanliness?
3. Do preps affect the diagnostic yield of SB CE?
4. Do prokinetics affect (a) GTT, (b) SBTT, c) completeness of SB examination?
5. Do prokinetics affect the diagnostic yield of SB CE?
6. Are there unique side effects related to the use of preps and prokinetics?
7. Does the use of preps and prokinetics affect patient acceptance of SB CE?
General Comments –
Limitations to the Consensus
Review Process

Approximately 70 reports
 Few large randomized controlled trials
 Fewer peer-reviewed publications
 Many small retrospective series
 Publication bias
 Multiple studies from same institution
 Different types of agents, different administration
schedules, combinations of agents, etc.
Preps

No validated scale is available
(subjective global assessment vs. more precise
analysis of individual frames)
 Total of 17 studies, 9 randomized
Only 3 of 9 included more than 100 patients
Only 1 of 9 published as peer-reviewed article
Preps –
Recent Abstracts

Pons et al., DDW 2006 Gastrointestinal Endosc 63(4):
AB M1284:
 291 patients
 (A) 4L clear liquids, (B) 90ml NaPhos, (C) 4L PEG
 NO SIGNIFICANT DIFFERENCES

Lapalus et al., ICCE 2006:AB 314850
 123 patients
 (A) 12 hour fast, (B) 90ml NaPhos
 NO SIGNIFICANT DIFFERENCE

Wi et al., Gastrointest Endosc 2006;63(4): AB M1310
 125 patients
 (A) 12 hour fast, (B) 90ml NaPhos, (C) 2L PEG
 IMPROVED VISIBILITY AND IMPROVED DIAGNOSTIC YIELD
WITH NaPHOS (BUT NOT WITH PEG)
Preps –
Peer-reviewed Article
 Viazis
et al. GIE 2004;60:534-8
Prospective, randomized, blinded
80 patients
PEG 2L vs. clear liquids only
Grading: “adequate” vs. “inadequate”
Cleansing “adequate”: 36pts (90%) vs. 24pts (60%)
Diagnosis established: 26pts (65%) vs. 12pts
(30%)
Preps –
Consensus Conclusions
 Preps
may not improve small-bowel
cleanliness.
 No definitive evidence that preps increase
diagnostic yield.
 No basis for recommending routine use in
clinical practice.
 No negative impact on transit times
demonstrated.
Prokinetics



Prokinetics have been less well-studied.
The clinically relevant endpoint of complete SB
examination (vs. GTT/SBTT) has not been consistently
reported.
Tegaserod (6 studies, none fully published) is possibly
effective for increasing the percentage of complete
studies.
 The impact on diagnostic yield is unknown.


Domperidone and metoclopramide have been less well
studied with conflicting results.
Erythromycin shortens GTT, but an effect on the rate
of complete SB exams has not been demonstrated.
Positioning / Other Issues

Right lateral decubitus position
 3 abstracts, non-randomized
 Evaluation of GTT only
 Statistically significant difference in 1 of 3 studies
 Too few data to reach firm conclusion

Predictive factors for incomplete SB exam
 Age, inpatient status and diabetes may be among the predictive
factors of incomplete SB examination
 Not enough data to draw firm conclusions regarding the use of
preps/prokinetics or postural maneuvers in these subgroups
Preps & Prokinetics
2006 Consensus Conclusions
1. Has a scale been validated to evaluate
SB cleanliness?
2. Do preps affect SB cleanliness?
3. Do preps affect the diagnostic yield of
SB CE?
4. Do prokinetics affect (a) GTT, (b) SBTT,
(c) completeness of SB examination?
5. Do prokinetics affect the diagnostic yield of
SB CE?
6. Are there unique side effects related to the use
of preps and prokinetics?
7. Does the use of preps and prokinetics affect
patient acceptance of SB CE?
No
Possibly No
Unknown
Yes (a)
Possibly Yes (b/c)
Unknown
No
Probably Yes