Contributed equally
Bowel preparation regimens for colon capsule endoscopy are not yet standardized since they are not well optimized. The aim of the present study was to evaluate the feasibility of a novel low-volume and sodium phosphate-free bowel preparation regimen for colon capsule endoscopy. A total of 31 patients were prospectively enrolled. In the novel regimen, on the day prior to examination, a low-fiber diet was permitted, 5 mg mosapride citrate was administered twice (1 h prior to lunch and supper) and 1 l polyethylene glycol was administered in the evening. On the day of the examination, an additional 1 l polyethylene glycol, 5 mg mosapride citrate and 200 mg simethicone were administered before capsule ingestion. Polyethylene glycol booster (0.5 l) was administered twice, at 1 and 4 h following capsule ingestion. Colon cleansing levels, ileocecal valve transit time and completion rate were evaluated. A total of 29 patients were included in the final analysis, 90% of whom achieved adequate preparation of the overall colon. Ileocecal valve transit time was 2.35±0.82 h and completion rate was 79.3%. The results revealed that the novel low-volume and sodium phosphate-free bowel preparation regimen for colon capsule endoscopy was feasible, with adequate colon cleansing and completion rates, and has the potential to be used as an alternative regimen.
Colorectal cancer (CRC) is the second most common type of cancer in western countries and has exhibited an increasing incidence in many Asian countries in recent decades (
The PillCam colon capsule endoscopy (CCE) may achieve direct visualization of the entire colon without sedation, radiation or air insufflation, which represents a non-invasive imaging system for exploring the colon (
The effectiveness of CCE partly depends on the cleanliness of the colon. An optimal bowel preparation regimen for CCE is required for a clean intestine, capsule propulsion and visualization of the whole large intestine. Previous studies have demonstrated bowel preparation regimens for CCE that generally consist of a split-dosage of polyethylene glycol (PEG) with the volume of 4 l, prokinetic agents and sodium phosphate (NaP) boosters (
The present study aimed to evaluate a novel low-volume and NaP-free bowel preparation regimen for CCE. In this regimen, the volume of PEG was reduced to 2 l and NaP was substituted with PEG as the booster. Colon cleansing quality and completion rate were assessed.
Between July 2013 and July 2014, a total of 31 patients were enrolled to the current prospective study at the Department of Gastroenterology, Nanfang Hospital, Southern Medical University (Guangzhou, China) in accordance with the following inclusion criteria: Aged 18–75 years, willing to accept CCE examination and providing signed informed consent. According to the criteria in a previously published study, exclusion criteria were as follows: Dysphagia or swallowing disorder, prior major abdominal surgery of the gastrointestinal tract, known or suspected bowel obstruction, presence of a cardiac pacemaker or other implanted electromedical devices and pregnancy (
The PillCam CCE (PillCam COLON, Given Imaging; Medtronic, Dublin, Ireland) was 11×31 mm in size and had two cameras, one at each end of the capsule, each capturing 2 images/sec. The angle of view for each imager was 156°. The capsule enters a 1 h delay mode following a 3-min initial function, then the system automatically restarts and functions for an additional 9 h. Captured images were transmitted to the data recorder via eight sensors. A rapid real-time viewer allowed a real-time view during a PillCam procedure. Following the examination, the recorded data was downloaded into the Given Imaging RAPID 4 workstation (Medtronic). Captured videos were reviewed by two physicians who had prior experience with colonoscopy and small intestine capsule endoscopy. Colon cleansing levels were then assessed, as described below.
As shown in
The four-point grading scale system reported by Leighton and Rex (
A total of 29 patients were included in the final analysis (male/female, 13/16; mean age, 35 years; age range, 24–61 years). Two patients (6%) were excluded as data was not acquired due to technical failure. Major clinical indications included physical examination, constipation, abdominal pain and diarrhea (
According to the four-point scale grading system, the results indicated that overall colon cleansing levels were rated as excellent in 1 patient (4%), good in 25 patients (86%) and fair in 3 patients (10%). No patients were rated as poor (
Ileocecal valve transit time (time from capsule ingestion to the first image of cecum) was 2.35±0.82 h. Furthermore, 93.1% (27/29) of capsules were located in the small intestine when they restarted following the 1 h delay mode. Two capsules were still in the stomach at this point and successfully travelled into the small intestine after the patients drank some water. Examination completion occurred in 79.3% (23/29) of patients. At the end of CCE examination in 2 cases, the capsule was in the descending colon, in 1 case it was in the transverse colon, in 2 cases it was in the ascending colon and in 1 case it was in the cecum (
At present, a standardized bowel preparation regimen is still not available. In previous studies, large volumes of PEG combined with a NaP booster regimen was most commonly applied (
Different bowel preparation regimens for CCE in previous studies have reported variable results; adequate colon cleansing ranged from 35 to 84% and completion rates ranged from 64 to 100% (
A booster is necessary for cleaning the colonic mucosa and improving capsule excretion. The efficacy of NaP as booster has been reported in previous studies (
There are other strategies that are favorable for improving the quality of colon cleansing and increasing completion rate. Several types of prokinetic agent have been used, such as tegaserod (
The present study demonstrated that a low-volume and NaP-free bowel preparation regimen was effective for colon capsule endoscopy. However, there were some limitations to the study, including the limited sample size and the absence of a controlled comparison with conventional colonoscopy. Furthermore, the study would be optimized if consecutive patients were included.
In conclusion, a novel low-volume and NaP-free bowel preparation regimen for CCE has been demonstrated to be feasible, with adequate colon cleansing levels and completion rate, and could therefore be used as an alternative regimen. Further studies should be performed in order to evaluate whether the completion rate can be increased, and the accuracy of CCE with the novel regimen should be compared with traditional colonoscopy in a randomized, controlled trial.
Images of colon cleansing levels rated by a four-point scale grading system. Cleansing levels were rated as (A) poor, (B) fair, (C) good or (D) excellent.
Colon cleansing levels in different colon segments and overall colon. Adequate levels (rated as good or excellent on a four-point scale grading system) were as follows: cecum, 61%; ascending colon, 84%; transverse colon, 88%; descending colon, 96%; rectosigmoid colon, 83%; and overall colon, 90%.
Conventional (
Regimen | ||
---|---|---|
Time | Conventional | Novel |
Day before examination | ||
All day | Clear liquids only | Low-fiber diet |
1 h before lunch | 5 mg mosapride citrate | |
1 h before supper | 5 mg mosapride citrate | |
6:00-9:00 p.m. | 3 l PEG | 1 l PEG |
Examination day | ||
6:00 a.m. | 1 l PEG | |
6:00-7:00 a.m. | 1 l PEG | |
7:30 a.m. | 5 mg mosapride citrate | |
7:45 a.m. | 20 mg domperidone | |
8:00 a.m. | Capsule ingestion | 200 mg simethicone |
8:30 a.m. | Capsule ingestion | |
9:30 a.m. | 0.5 l PEG | |
10:00 a.m. | 45 ml NaP + 1 l water | |
12:30 p.m. | 0.5 l PEG | |
2:00 p.m. | 30 ml NaP + 1 l water | |
3.00 p.m. | Snack (optional) | |
3:30 p.m. | Snack (optional) | |
4:30 p.m. | 10 mg bisacodyl |
PEG, polyethylene glycol; NaP, sodium phosphate.
Clinical indications of patients undergoing colon capsule endoscopy (n=33)
Clinical indication | n | Percentage |
---|---|---|
Physical examination | 8 | 24.2 |
Constipation | 6 | 18.2 |
Abdominal pain | 5 | 15.2 |
Diarrhea | 4 | 12.1 |
Abdominal distension | 3 | 9.1 |
Hematochezia | 2 | 6.1 |
Acid reflux and heartburn | 2 | 6.1 |
Recent change of bowel habits | 1 | 3.0 |
Prior ulcer in terminal ileum | 1 | 3.0 |
Crohn's disease | 1 | 3.0 |
A total of 29 patients were in the final analyses and as 4 of these patients suffered from two clinical indications, the sum of indications was 33.
Location of colon capsule endoscopy at different time points (n=29).
Time | Location | Patients (n) | Percentage |
---|---|---|---|
Restart after 1 h delay | Stomach | 2 | 6.9 |
Small intestine | 27 | 93.1 | |
End of examination | Haemorrhoidal plexus (visible) | 23 | 79.3 |
Descending colon | 2 | 6.9 | |
Transverse colon | 1 | 3.4 | |
Ascending colon | 2 | 6.9 | |
Cecum | 1 | 3.4 |