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Capsule endoscopy contraindications: complications and how to avoid their occurrence
Gastrointest Endoscopy Clin N Am 14 (2004) 61 – 65
Capsule endoscopy contraindications: complications and how to avoid their occurrence Jamie S. Barkin, MD, FACP, MACG*, Colm O’Loughlin, MB, MRCP(UK) University of Miami, School of Medicine/Mount Sinai Medical Center, Division of Gastroenterology, 4300 Alton Road, Miami Beach, FL 33140, USA
Wireless capsule endoscopy (WCE), which was approved for clinical use in the United States in August 2001, allows noninvasive visualization of the small intestinal mucosa and is a major innovation in the diagnosis of diseases of the small bowel. In concept, it is simple to use: the capsule endoscope (M2A, Given Imaging, Yoqneam, Israel) is easy to swallow and the information is easily retrieved. Conversely, it is based on our most advanced technical abilities. All procedures have risks, therefore it is our aim to elucidate the actual and potential complications of WCE and to point out how these can be avoided or handled successfully. Existing contraindications and relative contraindications to WCE are listed in Box 1. The capsule endoscope (CE) measures 11 mm in diameter and 26 mm in length. Oropharyngeal transfer of the CE into the esophagus is required at the initiation of the procedure. A large percentage of patients who may require WCE are older and may have any one of a wide spectrum of oropharyngeal diseases that impair transfer (Box 2). This may result in the inability to swallow the capsule or ineffectual swallowing with misplacement of the capsule in or around the pyriform sinuses or in the trachea. The CE can lodge at the cricopharyngeus and may be removed endoscopically by use of a Roth Retrieval Basket (US Endoscopy, Mentor, Ohio) [1]. Feitoza et al [2] reported one patient in whom the CE was retained in a Zenker’s diverticulum and required endoscopic removal and placement into the stomach. Thus, it is important to obtain a detailed ‘‘swallowing history’’ from patients who are to undergo WCE. We agree with Fleischer et al [1] that if dysphagia is present, video esophagograms with a 13-mm barium pill should be
* Corresponding author. E-mail address: [email protected] (J.S. Barkin). 1052-5157/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.giec.2003.10.016
62
J.S. Barkin, C. O’Loughlin / Gastrointest Endoscopy Clin N Am 14 (2004) 61–65
Box 1. Contraindications to WCE Contraindications
Known or suspected obstruction/stricture/fistula/ extensive Crohn’s disease Swallowing disorders Pseudo obstruction Motility disorders Cardiac pacemakers Implanted defibrillators and electromechanical devices
Relative contraindications
Pregnancy Longstanding nonsteroidal anti-inflammatory drug use Large and numerous diverticuli Zenker’s diverticulum Gastroparesis Previous pelvic or abdominal surgery
obtained before CE ingestion. Additionally, in patients with ineffectual attempts at swallowing, the CE may be aspirated into the trachea, requiring emergent bronchoscopy with foreign body removal [3]. The CE is propelled passively by peristalsis through the normal gastrointestinal lumen. Although it can potentially lodge at any or all narrowings of the lumen, usually natural passage occurs. The CE has been described as ‘‘hanging-up’’ for short periods at the lower esophageal sphincter (LES), pylorus, and at the ileocecal valve. Prolonged hang-ups (> 30 minutes at the LES or pylorus) are abnormal, although, in our experience, prolonged transit (> 30 minutes) through the ileocecal valve is unusual. CEs may be retained in the stomach in patients with gastroparesis or pyloric or duodenal narrowings. The anatomic narrowing can be overcome by pyloric or duodenal dilation. Once dilation is accomplished, the patient swallows the CE with minimal water intake. An upper endoscope is then passed in the usual manner. In the stomach, the CE is grasped with a Roth Retrieval Basket and advanced with the endoscope through the pylorus (in patients with gastroparesis) or postdilation through the pyloric channel or duodenal narrowing. In this distal location, the CE is discharged from the retrieval basket [4] to resume its journey through the small bowel. Additionally, M2A capsules can be hung-up in intestinal diverticulae [5]. Small bowel narrowings can result in nonnatural capsule passage requiring surgical intervention. To visualize these narrowings, perform a small bowel series
J.S. Barkin, C. O’Loughlin / Gastrointest Endoscopy Clin N Am 14 (2004) 61–65
63
Box 2. Causes of oropharyngeal dysphagia Structural pharyngoesophageal lesions Intrinsic lesions
Oropharyngeal carcinoma Esophageal carcinoma Benign esophageal tumor Esophageal web Zenker’s diverticulum Extrinsic lesions
Thyroid enlargement or tumor Vertebral spur
Neuromuscular diseases Central nervous system diseases
Cerebrovascular accident Parkinson’s disease Brainstem tumor Amyotrophic lateral sclerosis Syringobulbia Progressive bulbar paralysis
Cranial nerve diseases
Diabetes mellitus Recurrent laryngeal nerve palsy Myasthenia gravis
Skeletal muscle disease
Inflammatory myopathies Polymyositis Dermatomyositis Scleroderma
(SBS) before CE ingestion. However, such narrowings may not be visualized on SBS (see article in this issue by Rex). We have reported the incidence of nonnatural capsule passage that occurred in the initial world-wide WCE studies [6]. Surgical intervention was required in 0.75% (seven of 934 patients). In all seven of these patients, an endoluminal pathologic process was found, which
64
J.S. Barkin, C. O’Loughlin / Gastrointest Endoscopy Clin N Am 14 (2004) 61–65
explained the patients’ obscure gastrointestinal bleeding. Six of seven of our patients had a normal small bowel series. Sears et al [7] and Mergener et al [8] presented additional patients at the American College of Gastroenterology meeting in October 2002. Upon review, pathology was again found in these three patients. Additionally, Keuchel et al [9] reported a patient with a CE lodged above a partial small bowel obstruction secondary to adhesions. Thus, the retention of the capsule above an obstruction detects partially obstructing lesions of the small bowel, whether endoluminal or extraluminal. These patients usually do not have symptoms of mechanical obstruction, although one of Mergener’s patients did have obstruction symptoms [8]. Capsule nonpassage is usually detected by the investigator on visualization of an obstructing endoluminal lesion on review of the recorded images, or less commonly by patients’ complaint that they did not excrete the capsule. The patient with this complaint should undergo flat-plate and oblique radiographs of the abdomen to determine if the capsule was excreted or retained in the small bowel. The average small bowel passage time is 4 hours 26 minutes 3 seconds with a range of 17 minutes 24 seconds to 12 hours 34 minutes 56 seconds [Given Imaging, unpublished data]. The CE is expelled naturally after an average time of 72 hours (range 24 to 222 hours) [10]. If the capsule is visualized on the abdominal radiographs and is out of reach of an endoscope, laparotomy is indicated as pathologic lesions have been discovered in all reported patients. Taylor and colleagues [11] reported a patient whose M2A capsule was retained above a stricture for 3 months without adverse effect. This concept of capsule hang-up above partial luminal obstruction is similar to our use of a barium tablet to diagnose partial esophageal obstruction. In these patients, the liquid barium passes through and may fail to diagnose the problem, whereas the barium tablet may detect luminal narrowing. In the future, dissolvable radio-opaque capsules will be available for use in patients with suspected partial small bowel obstruction. Currently, the presence of a pacemaker is stated to be a contraindication to WCE. If capsule endoscopy could provide significant benefit to our patients, our approach is to explain the risks and benefits to the patient and consult with their cardiologist for approval. Some investigators place the activated capsule in close proximity to the electromechanical device while cardiac rhythms are reviewed continuously. Once no abnormalities are seen the patient swallows the capsule and leaves the ambulatory unit. Presently, we hospitalize the patient on a telemetry unit for the duration of the procedure. As per the general experience, we have had no problems with administering the capsule endoscope to patients with pacemakers [5]. Vasireddi et al [12] recently reported use of WCE in two patients with both permanent pacemakers as well as defibrillators. Fernandez-Diez and Ramirez-Armengol [13] reported four patients with cardiac pacemakers, two of whom had normal rhythm strips when the capsule was placed next to the pacemaker. The additional patients were studied by Medtronic’s engineers who did not detect interference of capsule and pacemaker working simultaneously. However, this has been performed in only a limited number of patients, and presently a large-scale survey of its safety is underway.
J.S. Barkin, C. O’Loughlin / Gastrointest Endoscopy Clin N Am 14 (2004) 61–65
65
In summary, WCE has fulfilled our aspiration to visualize the entire small intestinal mucosa noninvasively with few side-effects.
References [1] Fleischer DE, Heigh RI, Nguyen CC, Leighton JA, Sharma VK, Musil D. Video-capsule impaction at the cricopharyngeus: a first report of this complication and its successful resolution. Gastrointest Endosc 2003;57:427 – 8. [2] Feitoza AB, Gostout CJ, Knipschield MA, Rajan E. Video capsule endoscopy—is the recording time ideal? Am J Gastroenterol 2002;97(9):S-307. [3] Morandi E, Passoni GR, Stillittano D, et al. An unusual complication: capsule endoscopy in the bronchial tree. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 95. [4] Hollerbach S, Kraus K, Wiltert J, et al. Endoscopically assisted video capsule endoscopy of the small bowel in patients with functional gastric outlet obstructions. Endoscopy 2003;35:226 – 9. [5] Lewis BS. Complications and contraindications in capsule endoscopy. Gastroenterology 2002; 122(4):A330. [6] Barkin JS, Friedman S. Wireless capsule endoscopy requiring surgical intervention: the world’s experience. Am J Gastroenterol 2002;97(9):S-298. [7] Sears DM, Avots-Avotins A, White J, Culp K. Fortuitous M2A obstruction leads to localization of unsuspected vascular stricture. Am J Gastroenterol 2002;97(9):S-128. [8] Mergener K, Schembre DB, Brandabur JJ, Smith MA, Kozarek RA. Clinical utility of capsule endoscopy—a single center experience. Am J Gastroenterol 2002;97(9):S-299. [9] Keuchel M, Thaler CH, Csomos G, et al. Technical and medical problems associated with M2A video capsule endoscopy. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 145. [10] De Luca L, Di Geogio P, Rivellini G, et al. Capsule endoscopy: experience in southern Italy. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 135. [11] Taylor A, Miller A, Woods R, Desmond P. Long-term retained capsule without ill effects in a patient with ileal ulceration and undiagnosed stricture. In: Jacob H, editor. Proceedings of the first Given conference. Rome, 2002. Haifa, Israel: Rochash Printing; 2003. p. 115. [12] Vasireddi S, Tsompinidis A, Karpenos A. Safety of capsule endoscopy in patients with cardiac pacemakers and defibrillators: 2 case reports. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 89. [13] Fernandez-Diaz S, Ramirez Armengol JA. Cardiac pacemaker: a real contraindication for capsule endoscopy. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 137.
Capsule endoscopy contraindications: complications and how to avoid their occurrence Jamie S. Barkin, MD, FACP, MACG*, Colm O’Loughlin, MB, MRCP(UK) University of Miami, School of Medicine/Mount Sinai Medical Center, Division of Gastroenterology, 4300 Alton Road, Miami Beach, FL 33140, USA
Wireless capsule endoscopy (WCE), which was approved for clinical use in the United States in August 2001, allows noninvasive visualization of the small intestinal mucosa and is a major innovation in the diagnosis of diseases of the small bowel. In concept, it is simple to use: the capsule endoscope (M2A, Given Imaging, Yoqneam, Israel) is easy to swallow and the information is easily retrieved. Conversely, it is based on our most advanced technical abilities. All procedures have risks, therefore it is our aim to elucidate the actual and potential complications of WCE and to point out how these can be avoided or handled successfully. Existing contraindications and relative contraindications to WCE are listed in Box 1. The capsule endoscope (CE) measures 11 mm in diameter and 26 mm in length. Oropharyngeal transfer of the CE into the esophagus is required at the initiation of the procedure. A large percentage of patients who may require WCE are older and may have any one of a wide spectrum of oropharyngeal diseases that impair transfer (Box 2). This may result in the inability to swallow the capsule or ineffectual swallowing with misplacement of the capsule in or around the pyriform sinuses or in the trachea. The CE can lodge at the cricopharyngeus and may be removed endoscopically by use of a Roth Retrieval Basket (US Endoscopy, Mentor, Ohio) [1]. Feitoza et al [2] reported one patient in whom the CE was retained in a Zenker’s diverticulum and required endoscopic removal and placement into the stomach. Thus, it is important to obtain a detailed ‘‘swallowing history’’ from patients who are to undergo WCE. We agree with Fleischer et al [1] that if dysphagia is present, video esophagograms with a 13-mm barium pill should be
* Corresponding author. E-mail address: [email protected] (J.S. Barkin). 1052-5157/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.giec.2003.10.016
62
J.S. Barkin, C. O’Loughlin / Gastrointest Endoscopy Clin N Am 14 (2004) 61–65
Box 1. Contraindications to WCE Contraindications
Known or suspected obstruction/stricture/fistula/ extensive Crohn’s disease Swallowing disorders Pseudo obstruction Motility disorders Cardiac pacemakers Implanted defibrillators and electromechanical devices
Relative contraindications
Pregnancy Longstanding nonsteroidal anti-inflammatory drug use Large and numerous diverticuli Zenker’s diverticulum Gastroparesis Previous pelvic or abdominal surgery
obtained before CE ingestion. Additionally, in patients with ineffectual attempts at swallowing, the CE may be aspirated into the trachea, requiring emergent bronchoscopy with foreign body removal [3]. The CE is propelled passively by peristalsis through the normal gastrointestinal lumen. Although it can potentially lodge at any or all narrowings of the lumen, usually natural passage occurs. The CE has been described as ‘‘hanging-up’’ for short periods at the lower esophageal sphincter (LES), pylorus, and at the ileocecal valve. Prolonged hang-ups (> 30 minutes at the LES or pylorus) are abnormal, although, in our experience, prolonged transit (> 30 minutes) through the ileocecal valve is unusual. CEs may be retained in the stomach in patients with gastroparesis or pyloric or duodenal narrowings. The anatomic narrowing can be overcome by pyloric or duodenal dilation. Once dilation is accomplished, the patient swallows the CE with minimal water intake. An upper endoscope is then passed in the usual manner. In the stomach, the CE is grasped with a Roth Retrieval Basket and advanced with the endoscope through the pylorus (in patients with gastroparesis) or postdilation through the pyloric channel or duodenal narrowing. In this distal location, the CE is discharged from the retrieval basket [4] to resume its journey through the small bowel. Additionally, M2A capsules can be hung-up in intestinal diverticulae [5]. Small bowel narrowings can result in nonnatural capsule passage requiring surgical intervention. To visualize these narrowings, perform a small bowel series
J.S. Barkin, C. O’Loughlin / Gastrointest Endoscopy Clin N Am 14 (2004) 61–65
63
Box 2. Causes of oropharyngeal dysphagia Structural pharyngoesophageal lesions Intrinsic lesions
Oropharyngeal carcinoma Esophageal carcinoma Benign esophageal tumor Esophageal web Zenker’s diverticulum Extrinsic lesions
Thyroid enlargement or tumor Vertebral spur
Neuromuscular diseases Central nervous system diseases
Cerebrovascular accident Parkinson’s disease Brainstem tumor Amyotrophic lateral sclerosis Syringobulbia Progressive bulbar paralysis
Cranial nerve diseases
Diabetes mellitus Recurrent laryngeal nerve palsy Myasthenia gravis
Skeletal muscle disease
Inflammatory myopathies Polymyositis Dermatomyositis Scleroderma
(SBS) before CE ingestion. However, such narrowings may not be visualized on SBS (see article in this issue by Rex). We have reported the incidence of nonnatural capsule passage that occurred in the initial world-wide WCE studies [6]. Surgical intervention was required in 0.75% (seven of 934 patients). In all seven of these patients, an endoluminal pathologic process was found, which
64
J.S. Barkin, C. O’Loughlin / Gastrointest Endoscopy Clin N Am 14 (2004) 61–65
explained the patients’ obscure gastrointestinal bleeding. Six of seven of our patients had a normal small bowel series. Sears et al [7] and Mergener et al [8] presented additional patients at the American College of Gastroenterology meeting in October 2002. Upon review, pathology was again found in these three patients. Additionally, Keuchel et al [9] reported a patient with a CE lodged above a partial small bowel obstruction secondary to adhesions. Thus, the retention of the capsule above an obstruction detects partially obstructing lesions of the small bowel, whether endoluminal or extraluminal. These patients usually do not have symptoms of mechanical obstruction, although one of Mergener’s patients did have obstruction symptoms [8]. Capsule nonpassage is usually detected by the investigator on visualization of an obstructing endoluminal lesion on review of the recorded images, or less commonly by patients’ complaint that they did not excrete the capsule. The patient with this complaint should undergo flat-plate and oblique radiographs of the abdomen to determine if the capsule was excreted or retained in the small bowel. The average small bowel passage time is 4 hours 26 minutes 3 seconds with a range of 17 minutes 24 seconds to 12 hours 34 minutes 56 seconds [Given Imaging, unpublished data]. The CE is expelled naturally after an average time of 72 hours (range 24 to 222 hours) [10]. If the capsule is visualized on the abdominal radiographs and is out of reach of an endoscope, laparotomy is indicated as pathologic lesions have been discovered in all reported patients. Taylor and colleagues [11] reported a patient whose M2A capsule was retained above a stricture for 3 months without adverse effect. This concept of capsule hang-up above partial luminal obstruction is similar to our use of a barium tablet to diagnose partial esophageal obstruction. In these patients, the liquid barium passes through and may fail to diagnose the problem, whereas the barium tablet may detect luminal narrowing. In the future, dissolvable radio-opaque capsules will be available for use in patients with suspected partial small bowel obstruction. Currently, the presence of a pacemaker is stated to be a contraindication to WCE. If capsule endoscopy could provide significant benefit to our patients, our approach is to explain the risks and benefits to the patient and consult with their cardiologist for approval. Some investigators place the activated capsule in close proximity to the electromechanical device while cardiac rhythms are reviewed continuously. Once no abnormalities are seen the patient swallows the capsule and leaves the ambulatory unit. Presently, we hospitalize the patient on a telemetry unit for the duration of the procedure. As per the general experience, we have had no problems with administering the capsule endoscope to patients with pacemakers [5]. Vasireddi et al [12] recently reported use of WCE in two patients with both permanent pacemakers as well as defibrillators. Fernandez-Diez and Ramirez-Armengol [13] reported four patients with cardiac pacemakers, two of whom had normal rhythm strips when the capsule was placed next to the pacemaker. The additional patients were studied by Medtronic’s engineers who did not detect interference of capsule and pacemaker working simultaneously. However, this has been performed in only a limited number of patients, and presently a large-scale survey of its safety is underway.
J.S. Barkin, C. O’Loughlin / Gastrointest Endoscopy Clin N Am 14 (2004) 61–65
65
In summary, WCE has fulfilled our aspiration to visualize the entire small intestinal mucosa noninvasively with few side-effects.
References [1] Fleischer DE, Heigh RI, Nguyen CC, Leighton JA, Sharma VK, Musil D. Video-capsule impaction at the cricopharyngeus: a first report of this complication and its successful resolution. Gastrointest Endosc 2003;57:427 – 8. [2] Feitoza AB, Gostout CJ, Knipschield MA, Rajan E. Video capsule endoscopy—is the recording time ideal? Am J Gastroenterol 2002;97(9):S-307. [3] Morandi E, Passoni GR, Stillittano D, et al. An unusual complication: capsule endoscopy in the bronchial tree. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 95. [4] Hollerbach S, Kraus K, Wiltert J, et al. Endoscopically assisted video capsule endoscopy of the small bowel in patients with functional gastric outlet obstructions. Endoscopy 2003;35:226 – 9. [5] Lewis BS. Complications and contraindications in capsule endoscopy. Gastroenterology 2002; 122(4):A330. [6] Barkin JS, Friedman S. Wireless capsule endoscopy requiring surgical intervention: the world’s experience. Am J Gastroenterol 2002;97(9):S-298. [7] Sears DM, Avots-Avotins A, White J, Culp K. Fortuitous M2A obstruction leads to localization of unsuspected vascular stricture. Am J Gastroenterol 2002;97(9):S-128. [8] Mergener K, Schembre DB, Brandabur JJ, Smith MA, Kozarek RA. Clinical utility of capsule endoscopy—a single center experience. Am J Gastroenterol 2002;97(9):S-299. [9] Keuchel M, Thaler CH, Csomos G, et al. Technical and medical problems associated with M2A video capsule endoscopy. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 145. [10] De Luca L, Di Geogio P, Rivellini G, et al. Capsule endoscopy: experience in southern Italy. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 135. [11] Taylor A, Miller A, Woods R, Desmond P. Long-term retained capsule without ill effects in a patient with ileal ulceration and undiagnosed stricture. In: Jacob H, editor. Proceedings of the first Given conference. Rome, 2002. Haifa, Israel: Rochash Printing; 2003. p. 115. [12] Vasireddi S, Tsompinidis A, Karpenos A. Safety of capsule endoscopy in patients with cardiac pacemakers and defibrillators: 2 case reports. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 89. [13] Fernandez-Diaz S, Ramirez Armengol JA. Cardiac pacemaker: a real contraindication for capsule endoscopy. In: Jacob H, editor. Proceedings of the second Given conference on capsule endoscopy. Berlin, March 2003. Haifa, Israel: Rochash Printing; 2003. p. 137.