Endoscopically Assisted Video Capsule Endoscopy

We read with interest the paper by Hollerbach et al. on ”Endoscopically assisted capsule endoscopy of the small bowel in patients with functional gastric outlet obstruction” [1]. We would like to contribute further information on this issue, based on a patient with unexpected delay passage of the capsule endoscope through the esophagus and its subsequent management.

A 75-year-old woman with noninsulin-dependent diabetes mellitus was evaluated for obscure gastrointestinal bleeding. Prior upper and lower endoscopic examinations had been unrevealing. The patient had no symptoms of dysphagia or obstruction, and there was no discomfort reported during the procedure. However, subsequent analysis showed that the capsule was retained in the esophagus for up to 200 min (Figure [1 a] [b]) and was apparently flushed into the stomach when oral diet was resumed. In addition, the capsule failed to progress into the duodenum in the remaining examination time.

Figure 1 Delayed passage of the wireless capsule in the esophagus. There was no progression of the capsule in the esophagus from 24 min (a) up to 3 h 15 min (b) after swallowing. The timing of the images is shown in the upper left corners. c Chest radiograph showing cardiomegaly in this patient.

In view of the poor esophageal and gastric transit, the capsule endoscopy was repeated on a second occasion with endoscopic assistance. A standard polypectomy snare was first preloaded in the endoscope to grasp the capsule. An overtube was then gently inserted to guide the passage of the endoscope preloaded with the capsule through the pharynx. The capsule was then released in the distal duodenum under direct vision (Figure [2]). Subsequent analysis of the image showed multiple angiodysplasia in the small bowel, which represented the probable bleeding source.

Figure 2 Endoscopy-assisted placement of the wireless capsule in the duodenum. The endoscope, with the capsule grasped in the tip, is seen in the esophagus (a), stomach (b), and duodenum (c). d The snare was opened to release the capsule into the duodenum.

The capsule endoscope, which is 11 mm in diameter and 26 mm long, is swallowed by patients and actively propelled through the intestine by peristalsis [2] [3]. However, the transit time shows considerable variations among individuals [4], and failure of the capsule to progress through the bowel is still a major adverse event with this relatively noninvasive procedure. The delay in passage of the video capsule through the upper gastrointestinal tract in this elderly patient probably resulted from functional compression of the esophagus by the enlarged heart (Figure [1 c]), as well as from impaired esophageal or gastric motility. This case illustrates the need to screen for possible esophageal and gastric dysmotility in elderly patients before the use of capsule endoscopy.

References

• 1 Hollerbach S, Kraus K, Willert J. et al . Endoscopically assisted video capsule endoscopy of the small bowel in patients with functional outlet obstruction.  Endoscopy. 2003;  35 226-229
• 2 Ginsberg G G, Barkun A N, Bosco J J. et al . Wireless capsule endoscopy: August 2002.  Gastrointest Endosc. 2002;  56 621-624
• 3 Swain P. Wireless capsule endoscopy.  Gut. 2003;  52 (Suppl 4) iv48-50
• 4 Appleyard M N, Glukhovsky A, Jacob J. et al . Transit times of the wireless capsule endoscope [abstract].  Gastrointest Endosc. 2001;  53 AB122