Magnetic control does not appear to be clinically useful in im- proving CECR as a tool to assist in smallbowelcapsuleendoscopy and this was not affected by body habitus. However, the more ra- pid identification of the pylorus suggests that a magnet can exert a degree of control that allows endoscopist orientation in the stomach and which is likely to be clinically useful for gastric cap- sule endoscopy. Gastric preparation with a liter of ingested water containing simethicone offers better gastric mucosal clarity and distension than a 200-mL volume. It follows that a clean, ade- quately distended stomach is an important aspect of successful MACE, allowing the operator to identify gastric landmarks more easily and thus manipulate the capsule more effectively to achieve the required end. Importantly, MACE is a procedure that induces no measurable pain, discomfort or distress in patients. Further studies of control and preparation are needed to under- stand the potential of MACE as a noninvasive upper gastrointes- tinal diagnostic tool.
A recent meta-analysis on prokinetic agents and the completion rate in small-bowelcapsuleendoscopy showed that the use of prokinetics overall improved the comple- tion rate, without influencing the diagnostic yield . Previous studies on the effects of erythromycin in capsuleendoscopy suggested no beneficial effect of erythromycin on capsuleendoscopy completion rates [2-6], but it must be realized that these studies are probably underpowered, as no study included more than 50 patients per treatment arm. The primary aim of the our study was to analyze whether a single dose of orally administered erythromycin prior to capsuleendoscopy results in higher completion rates compared to domperidone in a prospective cohort study in 649 patients. Secondary endpoints were differ- ences in GGT, smallbowel transit time (SBTT) and the diagnostic yield of CE.
Although the technical specifications may vary between the different manufacturers, the principal engineering concepts are similar. The capsule is comprised of a light source, lens, complementary metal-oxide-semiconductor (CMOS) imager, battery, and a wireless transmitter. The physical size of the Pillcam SB2 capsule (Given Imaging) is 26 × 11 mm. The capsule is easily ingested, and propelled by natural peristalsis from mouth to anus. In patients with swallowing difficulties and certain esophageal pathologies (such as Zenker’s diverticulum) the capsule insertion can be facilitated by “front loading” on an endoscope. The battery is usually sufficient for 8–12 hours of video recording and transmission. The cecum is not reached by the end of the battery life in 8%–40% of the examinations. 4–7 However, in the vast majority of cases, the
leave some patients without a definitive diagnosis. In a study of 8 patients with positive serology (EMA or tTG) and a normal duodenal biopsy, VCE did not reveal any endoscopic features of celiac disease . Thus the investigators concluded that there was no benefit in performing VCE for this sub-group of patients; another similar study came to the same conclusions . There is however conflicting evidence. In a further study of 30 patients with Marsh 1 or 2 changes, only 6 of whom had positive EMA or tTG, one patient was diagnosed with celiac disease and another with SB CD on the basis of VCE appearances . It is clear that further work is required to assess the cost effectiveness of the use of VCE in these equivocal cases if the yield is as low as in this final study. VCE use may be justified however, in EMA or tTG positive patients with Marsh 1 or 2 changes or gastrointestinal symptoms particularly if they are unwilling to undergo further EGD and repeat biopsies. Patients with antibody-negative VA represent another diagnostic challenge since there is a wide range of differential diagnoses for VA. In the study of equivocal cases by Kurien et al. they also included a group of patients with antibody-negative VA to see if this increased the DY. Patients were extensively investigated for celiac disease including HLA phenotyping, by monitoring response to GFD and in some cases repeat duodenal biopsies. On the basis of VCE appearances and other ancillary tests 7 patients could be diagnosed with celiac disease and 2 further patients were diagnosed with SB CD as a cause for VA. Again this is a single small study and further work needs to be done to clarify the role of VCE in antibody-negative VA cases. This is particularly important as VCE alone is probably insufficient to confirm a diagnosis of celiac disease as endoscopic markers are not specific to celiac disease rather they are predictors of mucosal disease .
In the UK, the British Society of gastroenterology (BSG) does not mandate a minimum experience prior to undertaking capsule reading and at present there is no formal accreditation process as for other endoscopic procedures. International guidance suggests an experience of 10- 25 supervised cases should be performed prior to independent practice. These recommendations are largely inferred from secondary findings from studies on training in SBCE. A Korean study of 12 gastroenterology trainees specifically set out to determine the learning curve in SBCE. By reading one capsule per week, it was shown that it required 11 weeks to reach kappa coefficients of 0.80 between the trainees and an expert reader .
Smallbowelcapsuleendoscopy (SBCE) enables the whole of the smallbowel to be explored using a wireless capsule, which is swallowed and propelled through the gas- trointestinal tract by gut motility. According to the recently published international OMED–ECCO consensus, there are no specific SBCE diagnostic criteria for CD: the method has a high diagnostic yield in terms of identifying smallbowel mucosal lesions (even better than magnetic resonance imag- ing [MRI] or computed tomography [CT], judging from a few preliminary findings). 34,35 Such endoscopic lesions may
Results and Discussion: Smallbowelcapsuleendoscopy enables a non-invasive full-assessment of the smallbowel mucosa, with high diagnostic yield even for subtle lesions. In patients with obscure gastrointestinal bleeding, diagnostic yield is higher when performed early after the onset of bleeding. Endoscopic treatment of angioectasias using balloon-assisted enteroscopy may contribute to reduce rebleeding, while the risk of rebleeding in patients with “negative“ smallbowelcapsuleendoscopy is debatable. Cross-sectional imaging may be more accurate than smallbowelcapsuleendoscopy for the diagnosis of large smallbowel tumors. The Smooth Protruding Index on CapsuleEndoscopy (SPICE score) may help to differentiate submucosal tumors from innocent bulges. Smallbowelcapsuleendoscopy is also a key diagnostic instrument in patients with suspected Crohn’s disease and non-diagnostic ileocolonoscopy; it may also influence prognosis and therapeutic management, by determining disease extent and activity in patients with known Crohn’s disease. The role of smallbowelcapsuleendoscopy to investigate possible complications in patients with non-responsive coeliac disease is evolving.
A range of diagnostic tools can be used to determine the presence of Crohn’s disease, including radiology, endoscopy and serum antibody tests. Unfortunately, these diagnostic tools are often associated with low diagnostic yields and may require repeated testing before a diagnosis is even established. Smallbowelcapsuleendoscopy is also a useful tool in evaluation of the smallbowel for tumors such as lymphoma, carcinomas or carcinoids. This technology can be beneficial as an adjunctive diagnostic study in patients with coeliac sprue and for surveillance in patients with hereditary polyposis syndromes.
Previous research has indicated that CE may have a significant role in the detection of smallbowel pathology including polyps and cancer [24,25]. Schulmann et al demonstrated the ability of CE to detect a high fre- quency of polyps in the distal bowel of FAP patients . Our data supports these conclusions, with a signifi- cant range of findings, including medium to large polyps identified within the jejunum and ileum by CE. However in this study we were unable to confirm distal polyps with biopsy and it is possible that some abnormalities identified as polyps may not be adenomatous and could be other possibilities, for example lymphoid hyperplasia.
While conventional endoscopy diagnosis procedure consists in an exam that uses a flexible endoscope, with a video camera in the distal tip, to acquire intra-corporeal images from the GI tract as the endoscope is pushed into the patient ’ s body, a capsuleendoscopy exam relies in a small pill-like device, which is ingested and propelled by natural peristalsis through the GI tract, acquiring images while it travels . Therefore, major limitations of the conventional endoscopy are solved, since great skill and con- centration are required to navigate a conventional endoscope. Furthermore, and since no drugs are administered, some investigators maintain that the use of the capsule camera is a more physiological form of endoscopy than conventional push enteroscopy . By the time battery power expires, after about 8 transit hours through the GI tract, the camera will have captured about 55,000 images, which are transmitted to the hard drive in a belt worn by the patient . The capsule is excreted in the patient’s stool, usually within 24-48 h, and not reused . The time required to a physician to analyze the resulting video is, on average, 40-60 min . The reading time and interpretation of CE exams is very time consuming given that more than 50,000 images have to be reviewed [10,11], which contributes to the high cost of a CE exam . Thus, a com- puter assisted diagnosis tool to help the physicians to evaluate CE exams faster and more accurately is an important technical challenge and an excellent economical opportunity.
Colon capsuleendoscopy (CCE) was first put into clinical practice for the evaluation of the smallbowel in patients presenting with a gastrointestinal bleed unsuccessfully diagnosed by upper GI endoscopy and colonoscopy. With the recent advent of new technol- ogy, there is improved visualization of the intestinal mucosa and subsequently a higher sensitivity for identification of mural pathology, as seen in many recent prospective studies. CCE has now been studied both in the US and in Europe as a modality for colon cancer screening as well as for the diagnosis of in- flammatory bowel disease. When compared to con- ventional colonoscopy, CCE has been shown to have a sensitivity of greater than 88% for identifying 6 mm colonic polyps and over 90% for 1 cm polyps. There- fore its use as a screening tool for colon cancer must be evaluated. In patients suspected to have colitis secondary to inflammatory bowel disease (IBD), it has been shown to have 89% sensitivity for identify- ing active colonic inflammation. For higher risk pa- tients that requiring urgent colonoscopy, CCE offers an attractive alternative with the potential for a re- duced risk on iatrogenic injury. Colon capsule endo- scopy may also play an important role in the diagno- sis and surveillance of IBD with colonic manifesta- tions. Colonoscopy during active severe disease is as- sociated with an increased risk of perforation due to mucosal inflammation and friability, allowing us to consider CCE as a potentially safer alternative. CCE appears to be most useful for patients with acute lower GI bleeding, inflammatory bowel disease, colo- nic ischemia or other mucosal-based lesions.
Neither protection against nor treatment of LDA- induced small-bowel mucosal injuries has been established. In Japan, polaprezinc is commonly used for the treatment of gastric ulcer. Polaprezinc is a chelate compound consisting of zinc and L-carnosine that is thought to func- tion in protecting intercellular tight junctions [11,12], as an anti-oxidant , in preventing apoptosis [14-16], and in reducing inflammation . Omatsu et al.  speculated that polaprezinc protects rat intestinal epithelial (RIE-1) cells from indomethacin-induced apoptosis via its reactive oxygen species (ROS)-quenching effect. Mahmood et al.  reported that zinc carnosine prevented the rise in gut permeability caused by indomethacin in healthy volunteers,
Wireless capsuleendoscopy (WCE) is a state of art technique designed to allow gastroenterologist (physicians) to visualize the most inaccessible parts of the gastrointestinal (GI) tract. Endoscopy provides unprecedented diagnostic capabilities for certain ailments that no other method can match today, such as detecting polyps in the colon and ulcers or fungi in the GI tract. The gastroenterologist uses captured images for diagnosis of various diseases like Diarrhoea, Anaemia and internal bleeding, functioning of Bowel, Malabsorption, pain in Abdominal sections, Tumors and some cancers, Celiac sprue diseases. As well as the images captures and decompressed help the gastroenterologist to monitor the progress of treatment plans for the patient conditions. These methods provide much more accurate visualization gastrointestinal diseases than could be achieved in earlier endoscope systems, enabling physicians to more accurately diagnose patient ailments. Such demands force suppliers to deploy new techniques for high quality image capturing, image compression, image decompression , to reduce the size of capsule and the life of capsule ie the battery life so that sensor can capture more images of tract and this will help the physician in diagnosis of disease .
28]. If the lumen is narrowed because of a lesion the cap- sule might be permanently retained (defined as retention > 2 weeks) and surgical or endoscopic removal becomes necessary. Permanent retention is reported to occur in 0 to 13% of all CE procedures, depending on the definition for capsule retention and how the patients were selected [12,13,25-31]. In recent years CE has been performed in a large number of patients with known or suspected Crohn's disease [26,28,29,32] and even in some cases with suspected or known strictures [26,28]. However there are, to our knowledge, only two cases of acute smallbowel obstruction requiring acute surgery following a CE procedure published in the literature [27,29].
net into an open, small-bowel lumen not undergoing peristalsis). The endoscope and net were then removed. The reason for placing the capsule in the duodenum, and not releasing it in the stomach, was to avoid any possi- bility of prolonged retention of the capsule in the stom- ach. The entire length of the small intestine was ob- served, and the capsule was noted to enter the cecum just over 2 hours after placement in the duodenum. The positive finding, identified 43 minutes after commence- ment of the study, was the presence of multiple abnor- mal, dilated, blood vessels in a segment of proximal jejunum (Fig 1), where a small amount of fresh blood was present. A diagnosis of jejunal vascular malforma- tion with active bleeding was made. With the use of the surface abdominal wall sensors as guides, it was thought that the lesion was within the reach of pediatric enteros- copy.
Smallbowel bleeding accounts for 5-10% of GI bleeding. Contrary to western population infections are common cause, patients are two decades younger and overt GI bleeding was more common than occult bleeding. The etiological profile in the present study is similar to previous studies in India. The incidence of crohns and the use of NSAIDS and anticoagulants was also under raise. VCE or SBE/DBE are usual tools used for diagnosis. The diagnostic yield of capsuleendoscopy in the present study is 76%. Yield was higher in patients with overt bleeding and when VCE performed within 2 weeks of presentation. In the present study diagnostic yield of SBE/DBE combined was 77% and successful therapeutic intervention was performed in 50% of patients. Enteroscopy is slightly better than VCE and therapeutic intervention can be performed. Present study the rebleeding rate is 18% at the end of one year follow up. To our knowledge this is the first study comparing capsule and enteroscopy along with follow up. Future studies with large number and multiple centres are required.
In the absence of any evidence regarding the number of proce- dures required for training for individual certification of DAE competence, we were not able to set any minimum standard. Any recommendation in terms of the minimum annual number of procedures per endoscopist that are required to maintain adequate levels of quality, as well as which kind of training should be provided to beginners and/or to poor performers, would need to be based on an established strong association of poor quality with a minimum threshold number of proce- dures performed per year. Such data are currently unavailable. Nevertheless, after an extensive discussion the working group agreed the following suggestion: (i) training should only be provided by experienced enteroscopists in units with a suffi- cient volume of work (50 – 100 /year) to ensure an appropriate case mix, and trainee proficiency should be assessed by direct observation of procedures prior to being signed off by their su- pervisor; (ii) combined training in capsuleendoscopy and DAE may enhance lesion recognition and detection, and is encour- aged in those intending to perform DAE.
Of the 98 patients who underwent CE between February 2010 and March 2011 at Yokohama City University School of Medicine, CE expert selected 12 patients who had various lesions of the smallbowel and they were en- rolled in this study. All of the 12 patients had undergone CE for determination of the cause of obscure gastro- intestinal bleeding. The study protocol was approved by the Yokohama City University Hospital Ethics Commit- tee. Written informed consent was obtained from all the subjects prior to their participation in the study. The patients were instructed to swallow the CE capsule (Pill- Cam SB2; Given Imaging Ltd) with a solution of dimethicone after overnight fasting without any other preparation. The patients were allowed to drink clear liquids at 2 hours and eat light meals at 4 hours after swallowing the capsule. Two CE experts (with experi- ence of reporting more than 150 CE videos) separately read and interpreted the complete CE videos of the 12 patients. To confirm the diagnostic accuracy, intra- observer differences were calculated. If discrepancies were observed, a consensus was reached after the find- ings were reviewed simultaneously by both the CE experts.
We do large intestine transit time with maintenance of shortening of the small intestine discharge time with around 60 minutes, and we reduce intention, a fluid intake at enforcement of the large intestine capsule endoscope, and in the future examination think about the maintenance of the intestinal irrigation de- gree that we come to be able to depict a large intestine lesion surely safely.
into glycerol and ricinoleic acid by lipase in the small intestine. Ricinoleic acid causes catharsis by stimulating the small intestine. Although the use of Gastrografin  has been reported, we used castor oil because it is inexpensive and is covered by the nation- al health insurance system of Japan. The capsule excretion rate was 53.3% in dialysis patients treated according to the original protocol of bowel preparation. However, cap- sule endoscopes were excreted in all patients in the castor oil-treated group, which in- cluded only four dialysis patients. The capsule endoscope was excreted even in one of these dialysis patients who was using a wheelchair and was unable to walk. The capsule transit time after bowel preparation with castor oil was shortened, and the booster do- sage was also reduced. Thus, the modified protocol of bowel preparation appears to be beneficial for not only dialysis patients, but also many other patients.