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Colon capsule endoscopy (CCE) is a well-known method for the detection of colorectal lesions. Nevertheless, there are no studies reporting the accuracy of TOP 100, a CCE software tool, for the automatic detection of colorectal lesions in CCE. We aimed to evaluate the performance of TOP 100 in detecting colorectal lesions in patients submitted to CCE for incomplete colonoscopy compared with classic reading. A retrospective cohort study including adult patients submitted to CCE (PillCam COLON 2; Medtronic) for incomplete colonoscopy. Blinded for each other's evaluation, one experienced reader analyzed the TOP 100 images and the other performed classic reading to identify colorectal lesions. Detection of colorectal lesions, namely polyps, angioectasia, blood, diverticula, erosions/ulcers, neoplasia, and subepithelial lesions was assessed and TOP 100 performance was evaluated compared with the gold standard (classic reading). A total of 188 CCEs were included. Prevalence of colorectal lesions, polyps, angioectasia, blood, diverticula, erosions/ulcers, neoplasia, and subepithelial lesions were 77.7, 54.3, 8.5, 1.6, 50.0, 0.5, 0.5, and 1.1%, respectively. TOP 100 had a sensitivity of 92.5%, specificity of 69.1%, negative predictive value of 72.5%, positive predictive value of 91.2%, and accuracy of 87.2% for detecting colorectal lesions. TOP 100 had a sensitivity of 89.2%, specificity of 84.9%, negative predictive value of 86.9%, positive predictive value of 87.5%, and accuracy of 87.2% in detecting polyps. All colorectal lesions other than polyps were identified with 100% accuracy by TOP 100. TOP 100 has been shown to be a simple and useful tool in assisting the reader in the prompt identification of colorectal lesions in CCE., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pan-intestinal capsule endoscopy (PCE) evaluates the small bowel and colon noninvasively. This study evaluated diagnostic accuracy and safety of PCE vs. colonoscopy as first-line examination in suspected mid-lower gastrointestinal bleeding (MLGIB)., Methods: In this prospective, single-center, single-blinded cohort study, consecutive patients with suspected MLGIB underwent PCE followed by same-day colonoscopy. Diagnostic accuracy for potentially hemorrhagic lesions (PHLs; combined diagnosis by PCE + colonoscopy) and incidence of adverse events were assessed., Results: 100 patients were included (median age 70 [range 18-92] years; 65% female). PHLs were diagnosed in 46 patients, including small-bowel and/or colon angioectasias in 32. PCE correctly identified 54 individuals without PHLs, and 95.7% (44/46) of those with PHLs vs. 50.0% (23/46) for colonoscopy (P<0.01). PHLs were detected by PCE alone in 65.2% (30/46), both examinations in 28.3% (13/46), and colonoscopy alone in 6.5% (3/46). PHLs were diagnosed at the ileocolonic region in 28% of patients, with PCE diagnosing 25/28 cases (89.3%) and colonoscopy diagnosing 23/28 (82.1%; P=0.13). Interventional procedures were performed at colonoscopy in 13/81 patients with iron-deficiency anemia (16.0%) vs. 6/19 patients with overt bleeding (31.6%; P<0.01). No significant adverse events occurred with PCE vs. 2% with colonoscopy., Conclusions: In patients with MLGIB, PCE avoided further invasive procedures in >50% of patients. PCE was safe and more effective than colonoscopy in identifying PHL both in the small bowel and colon. These results support the potential use of PCE as first-line examination in patients with suspected MLGIB., Competing Interests: B. Rosa has received consultancy fees from Medtronic, unrelated to the current work. T. Cúrdia Gonçalves, M.J. Moreira, F. Dias de Castro, B. Sousa-Pinto, M. Dinis-Ribeiro, and J. Cotter declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: The rate of adequate cleansing (ACR) and complete examinations (CR) are key quality indicators in capsule colonoscopy (CC) and pan-intestinal capsule endoscopy (PCE)., Aims: To evaluate the efficacy of bowel preparation protocols regarding ACR and CR., Methods: We conducted a systematic review and meta-analysis, search terms regarding colon capsule preparation, publication date from 2006/01, and date of search 2021/12, in six bibliographic databases. Multiple steps of the cleansing protocol were assessed: diet, adjunctive laxatives, purgative solution, use of prokinetic agents, and "booster". The meta-analytical frequency of ACR and CR was estimated, and subgroup analyses performed. Strategies associated with higher ACR and CR were explored using meta-analytical univariable and multivariable regression models., Results: Twenty-six observational studies and five RCTs included (n = 4072 patients). The pooled rate of ACR was 72.5% (95% C.I. 67.8-77.5%; I 2  = 92.4%), and the pooled rate of CR was 83.0% (95% C.I. 78.7-87.7%; I 2  = 96.5%). The highest ACR were obtained using a low-fibre diet [78.5% (95% C.I. 72.0-85.6%); I 2  = 57.0%], adjunctive laxatives [74.7% (95% C.I. 69.8-80.1%); I 2  = 85.3%], and split dose < 4L polyethylene glycol (PEG) as purgative [77.5% (95% C.I. 68.4-87.8%); I 2  = 47.3%]. The highest CR were observed using routine prokinetics prior to capsule ingestion [84.4% (95% C.I. 79.9-89.2%); I 2  = 89.8%], and sodium phosphate (NaP) as "booster" [86.2% (95% C.I. 82.3-90.2%); I 2  = 86.8%]. In univariable models, adjunctive laxatives were associated with higher ACR [OR 1.81 (95% C.I. 1.13; 2.90); p = 0.014]. CR was higher with routine prokinetics [OR 1.86 (95% C.I. 1.13; 3.05); p = 0.015] and split-dose PEG purgative [OR 2.03 (95% C.I. 1.01; 4.09), p = 0.048]., Conclusions: Main quality outcomes (ACR, CR) remain suboptimal for CC and PCE. Despite considerable heterogeneity, our results support low-fibre diet, use of adjunctive sennosides, split dose < 4L PEG, and routine prokinetics, while NaP remains the most consistent option as booster., (© 2023. The Author(s).)

Background: Optimal strategies for using small-bowel capsule endoscopy (SBCE) in established small-bowel Crohn's disease (CD) remain uncertain. Mucosal healing (MH) has emerged as a valuable predictor of a flare-free disease. We aimed to evaluate the occurrence of disease flare on patients with small-bowel CD and MH, as well as to create a score identifying patients in higher risk for this outcome., Methods: We analyzed consecutive patients submitted to SBCE for assessment of MH and included those where MH was confirmed. The incidence of disease flare was assessed during follow-up (minimum 12 months). A score predicting disease flare was created from several analyzed variables., Results: From 47 patients with MH, 12 (25.5%) had a flare (versus 48.3% in excluded patients without MH; p = 0.01). Age ≤ 30 years (OR  = 70; p  = 0.048), platelet count ≥ 280 × 10 3 /L (OR  = 12.24; p  =  0.045) and extra-intestinal manifestations (OR  =  11.76; p  =  0.033) were associated with increased risk of CD flare during the first year after SBCE with MH. These variables were used to compute a risk-predicting score-the APEX score-which assigned the patients to having low (0-3 points) or high-risk (4-7 points) of disease flare and had excellent accuracy toward predicting disease relapse (AUC  =  0.82; 95%CI 0.64-0.99)., Conclusion: Patients with small-bowel CD and MH were not free of disease flares on the subsequent year, despite presenting lower rates when compared to those without MH. The APEX score demonstrated excellent accuracy at stratifying patients relapse risk and guiding further therapeutic options for patients achieving MH., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Competing Interests: Competing interests: None declared.

Background and Aims: Terminal ileitis is a common condition and may be associated with a wide variety of diseases, mostly Crohn's disease. Although small bowel capsule endoscopy (SBCE) is a valuable diagnostic tool for small-bowel diseases, data regarding its diagnostic impact on isolated terminal ileitis are sparse. The aim of this study was to evaluate the diagnostic value of SBCE for isolated terminal ileitis detected during ileocolonoscopy and to assess predictive factors for Crohn's disease diagnosis., Methods: This is a retrospective study including consecutive patients undergoing SBCE after diagnosis of terminal ileitis without colonic mucosal abnormalities on ileocolonoscopy between January 2016 and September 2019., Results: This included 102 patients with isolated terminal ileitis on ileocolonoscopy. Positive findings on SBCE were found in 82.4% of patients. After performing SBCE, 61.8% of patients had a final diagnosis, being Crohn's disease the most common (34.3%), followed by NSAIDs enteropathy (12.7%). Extraintestinal manifestations (P = 0.003), weight loss (P = 0.02), abnormal imaging (P = 0.04) and positive SBCE findings (P = 0.001) were independently associated with Crohn's disease diagnosis. Regarding SBCE, presence of proximal small-bowel disease (P = 0.02), diffuse findings (P = 0.002) and moderate to severe inflammatory activity (Lewis score ≥ 790) (P < 0.001) were independently associated with Crohn's disease diagnosis., Conclusion: SBCE is a valuable tool that should be systematically used in patients with isolated terminal ileitis on ileocolonoscopy, since it revealed a high diagnostic yield, supporting a definite diagnosis in almost two-thirds of patients, and Crohn's disease diagnosis in approximately one-third of patients. A diagnosis of Crohn's disease should be considered when a patient with terminal ileitis on ileocolonoscopy shows proximal involvement, diffuse findings and/or moderate to severe inflammatory activity on SBCE., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Small bowel capsule endoscopy (SBCE) is the gold standard for mid-gastrointestinal bleeding (MGIB). No score has been developed to predict the risk of small bowel rebleeding after SBCE., Objective: Creating a predictive small bowel rebleeding risk score for MGIB, after initial SBCE., Methods: Retrospective, single center study, including SBCEs for MGIB, from June 2006 to October 2016. The minimum follow-up was 12 months. Univariate analysis and a multivariable Cox regression model tested the association with rebleeding. Statistically significant variables were used to compute the score. The score's accuracy was tested through a receiver operating characteristic (ROC) curve. A classification tree identified risk groups. For internal validation, we performed a 5-fold cross validation., Results: We assessed 357 SBCEs for MGIB, of which 88 (24.6%) presented rebleeding during follow-up. Seven variables were used to compute a risk-predicting score - the RHEMITT score - namely, renal disease; heart failure; endoscopic capsule P1/P2 lesions; major bleeding; incomplete capsule; tobacco consumption; and endoscopic treatment. The score presented good accuracy toward the outcome (area under the curve ROC 0.842, 95% CI 0.757-0.927). We established 3 rebleeding risk groups: low (0-3 points); intermediate (4-10 points); and high (+11 points)., Conclusion: A new MGIB score, named RHEMITT, accurately anticipates the individual risk of small bowel rebleeding after initial SBCE., (© 2019 S. Karger AG, Basel.)

Background: In small bowel capsule endoscopy (SBCE), the presence of residue may compromise diagnostic accuracy., Aims: To assess differences in quality of visualisation and diagnostic yield of SBCE using 3 different preparation protocols., Methods: Prospective, randomized, blind, pilot study. Protocol A:Clear liquids diet the day before the examination with fasting from 8p.m.; Protocol B:Protocol A + 2 pouches of Moviprep ® (polyethylene glycol electrolyte solution + sodium ascorbate) in 1 L of water from 8p.m. of the day before the examination; Protocol C: Protocol A + 2 pouches of Moviprep ® in 1 L of water consumed after real-time confirmation of capsule arrival at small bowel. Small bowel preparation was classified by two experienced physicians, considering the percentage of the examination during which mucosal observation was adequate: Excellent(>90%); Good(90-75%); Fair(75-50%); Poor(<50%)., Results: 101 patients randomized to the 3 protocols (A 37, B 31, C 33 patients). Protocol C had an excellent/good small bowel preparation in a higher percentage of examinations for both readers(Reader 1-A:37.8% vs B:45.2% vs C:78.8%, p = 0.002 and Reader 2 -A:37.8% vs B:41.9% vs C:75.8%, p = 0.003). Also, protocol C had a higher detection of angioectasia (A:5.4% vs B:9.7% vs C:27.3%, p = 0.022)., Conclusions: The administration of Moviprep ® after the capsule had reached the small bowel was associated with a better small bowel preparation and a higher detection of angioectasia., (Copyright © 2019 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Small bowel capsule endoscopy (SBCE) is a firstline examination in patients with suspected Crohn's disease (CD) after negative ileocolonoscopy. Fecal calprotectin (FC) is a noninvasive marker of intestinal inflammation. The aim of this study was to evaluate the predictive value of FC in inflammatory activity detected by SBCE in patients with suspected CD., Methods: This is a retrospective study including patients who underwent SBCE for suspected CD between March 2015 and October 2016. FC was measured within 1 week of SBCE. Inflammatory activity at SBCE was considered significant when the Lewis score (LS) was ≥135. FC correlation with LS was assessed using the Spearman correlation. The diagnostic accuracy of FC for significant inflammatory activity at SBCE was calculated by the area under the receiver operating characteristic curve (AUC)., Results: Seventy-five patients were included: 52 females (69.3%), with a mean age of 37 years. SBCE detected significant inflammatory activity (LS ≥ 135) in 42 patients (56%), and FC was positively correlated to LS (rank correlation = 0.56; P < 0.001). The AUC of FC was 0.854 for significant inflammatory activity (LS ≥ 135). For values of FC ≥100 µg/g, an LS ≥135 was found in 33 of 37 patients (89.2%, P < 0.001), corresponding to a sensitivity, specificity, positive predictive value, and negative predictive value of 78.6%, 87.9%, 89.2%, and 76.3%, respectively., Conclusions: FC has shown a good ability to predict significant inflammatory activity in SBCE in patients with suspected CD. Thus, FC proved to be a useful tool to select patients with suspected CD for SBCE., (© 2018 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Study Aims: Available scoring systems to assess the risk for major bleeding in patients on chronic anticoagulation seem inadequate in predicting higher diagnostic yields of small bowel capsule endoscopy (SBCE) or higher rebleeding rates in patients with suspected small bowel bleeding. The aim of this study was to evaluate the ability of the new ORBIT score in predicting positive findings of SBCE or higher rebleeding rates in chronically anticoagulated patients with suspected small bowel bleeding., Patients and Methods: Retrospective analysis of 570 patients who consecutively underwent SBCE for the study of suspected small bowel bleeding. For each of the 67 patients who were on chronic anticoagulation, ORBIT score (Older age, Reduced hemoglobin/hematocrit, Bleeding history, Insufficient kidney function and Treatment with antiplatelets) was calculated. Patients were classified as high-risk (ORBIT score ≥4) or low/intermediate-risk (ORBIT score <4). Data on SBCE findings, diagnostic yield and rebleeding were compared between groups., Results: When ORBIT score was calculated, 41 and 26 patients were classified as low/intermediate-risk and high-risk, respectively. When low/intermediate-risk and high-risk groups were compared, no differences were found in the diagnostic yield of SBCE (39.0% vs. 23.1%; p = .176). However, in high-risk patients, rebleeding was significantly more common than in low/intermediate-risk patients (80.0% vs. 36.6%; p = .003)., Conclusions: In patients presenting with suspected small bowel bleeding and on chronic anticoagulation, the new ORBIT score seems promising in identifying those with a higher risk of rebleeding, in whom a closer follow-up and a more aggressive diagnostic and therapeutic strategy is advisable.

Aim: To identify risk factors for P1 lesions on small bowel capsule endoscopy (SBCE) and to describe the natural history of anemic patients with such type of lesions., Methods: One hundred patients were consecutively selected for a case-control analysis performed between 37 cases with P1 lesions and 63 controls with negative SBCE. Age, gender, comorbidities and regular medication were collected. Rebleeding, further investigational studies and death were also analyzed during the follow-up., Results: No significant differences on gender, median age or Charlson index were found between groups. Although no differences were found on the use of proton pump inhibitors, acetylsalicylic acid, anticoagulants or antiplatelet agents, the use of non-steroidal anti-inflammatory drugs (NSAID) was associated with a higher risk of P1 lesions (OR = 12.00, 95%CI: 1.38-104.1). From the 87 patients followed at our center, 39 were submitted to additional studies for investigation of iron-deficiency anemia (IDA), and this was significantly more common in those patients with no findings on SBCE (53.7% vs 30.3%, P = 0.033). A total of 29 patients had at least one rebleeding or IDA recurrence episode and 9 patients died of non-anemia related causes but no differences were found between cases and controls., Conclusion: P1 lesions are commonly found in patients with IDA submitted to SBCE. The use of NSAID seems to be a risk factor for P1 lesions. The outcomes of patients with P1 lesions do not differ significantly from those with P0 lesions or normal SBCE.

Background and Aim: A significant proportion of patients presenting with obscure gastrointestinal bleeding (OGIB) have negative small bowel capsule endoscopy (SBCE) examinations, and yet remain at risk of rebleeding. We aimed to evaluate whether a second-look review of SBCE images using flexible spectral color enhancement (FICE) may improve the detection of potentially bleeding lesions., Materials and Methods: This was a retrospective, single-center study including consecutive patients with OGIB subjected to SBCE, whose standard white light examination was nondiagnostic. Each SBCE was reviewed using FICE 1. New findings were labeled as either P1 or P2 lesions according to bleeding potential. Patients were followed up to assess the incidence of rebleeding., Results: A total of 42 consecutive patients were included. Sixteen patients (38%) experienced rebleeding after a mean follow-up of 26 months. Review of SBCE images using FICE 1 enabled the identification of previously unrecognized P2 lesions, mainly angioectasias, in nine patients (21%) and P1 lesions, mainly erosions, in 26 patients (62%). Among patients who experienced rebleeding, 13/16 (81%) were diagnosed with P1 lesions with FICE 1 (P=0.043), whereas 3/16 (19%) had confirmed nondiagnostic SBCE and only 1/16 (6%) had newly diagnosed P2 (plus P1) lesions. An alternative source of bleeding outside the small bowel was found in only 3/16 (19%) patients with rebleeding during the follow-up., Conclusion: In a significant proportion of patients with OGIB, FICE 1 may detect potentially bleeding lesions previously missed under conventional white light SBCE. Review of nondiagnostic SBCE with FICE 1 may be a valuable strategy to obviate the need for further investigations in patients with OGIB, particularly for those who experience rebleeding.

Background/aim: Small bowel capsule endoscopy (SBCE) is currently a fundamental tool in the etiological study of obscure gastrointestinal bleeding (OGIB). However, the impact of a negative exam and the risk of rebleeding are not entirely known. The aim of this study was to evaluate the outcomes of patients with OGIB and a negative SBCE examination in terms of follow-up duration, additional diagnostic studies, and achievement of a diagnosis as well as to assess the incidence of rebleeding and possible associated factors., Materials and Methods: We retrospectively analyzed 256 patients who consecutively underwent an SBCE examination for the study of OGIB between April 2006 and December 2011, and then selected the 79 whose results excluded potentially bleeding lesions. Eleven patients were lost to follow-up and the remaining 68 were eligible for a nested case-control analysis. Pre-SBCE and post-SBCE information was collected, including follow-up interval and incidence of rebleeding, defined as admission to the hospital for symptomatic anemia, need for blood transfusion, decrease in hemoglobin value of greater than 2 g/dl, or evidence of melena or hematochezia. Univariate analysis included age, sex, OGIB presentation (occult or visible), hemoglobin levels at presentation, and comorbidities., Results: In the 68 patients analyzed, the mean age was 52±18 years and 61.8% were women. The OGIB was occult in 54 patients (79.4%) and overt in 14 patients (20.6%). Patients were followed up for an average of 32 months. Thirty-nine patients (57.4%) underwent further diagnostic investigations during the period of follow-up and a cause for the gastrointestinal bleeding was found in five of them. Rebleeding was documented in 16 (23.5%) patients, occurring on average 15±13.8 months after the SBCE. Male sex was associated significantly with higher incidence of rebleeding (P=0.004)., Conclusion: Approximately one quarter of patients with OGIB and negative SBCE examination will experience rebleeding, with higher incidence among men; thus, a negative SBCE in this setting is not reassuring. As the vast majority of rebleeding episodes seem to occur within the following 2 years after SBCE, the maintenance of regular medical surveillance during the above-mentioned period of time after a negative SBCE seems advisable.

This article compares the efficacy and safety of two strategies for completing a previous incomplete colonoscopy: colon capsule endoscopy (CCE) and repeat conventional colonoscopy. The study included 192 CCE procedures and 181 repeat colonoscopies. The rate of appropriate colon examination with CCE was not significantly different from the cecal intubation rate of repeat colonoscopy. Both strategies were found to be effective and safe options for completing an incomplete colonoscopy. Factors such as patient preferences, comorbidities, costs, availability, and local expertise should guide the choice between the two options. [Extracted from the article]

This article discusses the impact of a structured capsule endoscopy (CE) training program on CE proficiency. The study included 57 participants who performed pretraining and posttraining assessments using the Capsule Endoscopy Training Assessment (CETA) tool. The results showed a significant improvement in participants' mean CETA score after training, with 87.7% of participants achieving the posttraining learning goal. The study also found that participants with previous experience in flexible endoscopic techniques and CE had higher pretraining scores but did not significantly differ in posttraining scores compared to those without experience. Overall, the study suggests that the CE training program was beneficial in improving CE proficiency, particularly for less experienced participants. [Extracted from the article]