A Single-center Audit on Utility of Capsule Endoscopy in Diagnosing Small-bowel Diseases

Video capsule endoscopy (CE) is an invaluable tool in investigating various gastrointestinal diseases.[1] Studies have highlighted that it is a reliable, noninvasive, and cost-effective method to examine the entire small bowel.[1] Data on CE in India are limited to high-volume centers, and it has seldom been studied in Central India.[2-4] Our study was undertaken to determine the indications and findings of CE at our center. This retrospective study included patients aged 18 years and above who underwent CE (PillCam, Given Imaging, Yoqneam, Israel) with adequate bowel preparations at our center between 2010 and 2025. Before CE, a thorough history, physical examination, and investigations were reviewed. To avoid complications, all patients were subjected to computed tomography enteroclysis to rule out obvious stricture. Total duration of the recording was approximately 8 h. Patients were given an injectable prokinetic (metoclopramide) if capsule transit was slow (i.e. if the capsule remained in the stomach for more than 4 h). Patients could be mobile if required and were given a light diet/liquids during the period of the study. The demographic details, indications, and findings were recorded in a predesigned pro forma. CE images were downloaded and examined by a single investigator (MJ) with adequate experience of using software (Rapid Reader; Given Imaging, Yoqneam, Israel). Data were entered into a Microsoft Excel sheet. Data were represented as numbers, percentages, median, and range as applicable. The study group included 61 patients (37 males and 24 females) with a median age of 63.5 years (25–77 years). The indications for CE study included workup for obscure gastrointestinal bleed (48, 78.7%), to identify small-bowel involvement in patients with suspected or diagnosed inflammatory bowel disease (7, 11.5%), unexplained iron deficiency anemia (2, 3.3%), unexplained abdominal pain with anemia (1, 1.6%), and chronic diarrhea (3, 4.8%). Ten patients had a negative study in which no lesions were noted. This suggested that the diagnostic yield of CE was 83.6% (51/61). Those with a positive study had the following findings [Figure 1] – 33 patients had erosions, 3 had arteriovenous (AV) malformations, 11 had ulcers, and 4 had polyps (3 – jejunal and 1 – ileal). None of the patients had capsule retention, and none of the cases had multiple lesions. Based on clinical history and CE findings, the final diagnosis for ulcerative lesions was categorized as nonsteroidal anti-inflammatory drug-induced ulcers (n = 8) and Crohn’s disease (n = 3). For patients with jejunal and ileal polyps, follow-up was not available as they were referred for CE from other hospitals. Among patients with erosions, the majority were labeled as drug-induced (28/33), and few (5/33) were considered secondary to already diagnosed inflammatory bowel disease.Figure 1: Representative images of capsule endoscopy (a) ulcer with stricture; (b) ulcer; (c) polyp; (d) AV malformationA study by Ghoshal et al.[2] noted that out of 350 patients (age 52.4 ± 17.4 years; 248 [70.9%] male) undergoing CE for obscure and overt small-bowel bleed, lesions were detected in 244 (69.7%) patients. The single lesions included vascular malformations (52, 14.9%), ulcer/erosion (47, 13.4%), tumor (24, 6.9%), hookworm (19, 5.4%), stricture (15, 4.3%), hemobilia (1, 0.3%), and blood without identifiable lesion (9, 2.6%). Of 72 with multiple lesions, ulcer with stricture was the most common finding (12.3%). Another study from western India reported that out of 68 patients who underwent CE for obscure bleed, the yield was 65%. The lesions identified in descending order were angiodysplasia, Crohn’s disease, nonsteroidal anti-inflammatory drug enteropathy, small-bowel ulcers, jejunal and ileal polyps, intestinal lymphangiectasis, and ileal hemangiomas.[3] The largest study from India studied 1155 CE and noted that 1.8% patients had capsule retention. The diagnostic yield of CE did not vary significantly with age.[4] Our experience is limited to 61 patients. Nonspecific erosions were the most common finding in our cohort (33,54.1%), followed by ulcers (11,18%), polyps (4, 5.5%), and AV malformations (3,4.9%). This highlights that there is regional variation in India in capsule findings, as indications and accessibility to CE vary across regions. CE is today considered the first-line small-bowel investigative modality, which provides more sensitive mucosal imaging than comparators. It has several advantages – noninvasive, nonirradiating, and low risk of complications. Regular use of laxatives has significantly improved visualization, and the limiting factor remains the experience of the capsule endoscopist. This should be performed at a speed comfortable to the viewer, probably at a maximum of 15 frames per second.[5] The present study is limited by a small sample size and single-center retrospective design. Despite these shortcomings, the study highlights that CE is an important noninvasive tool in identifying various diseases of the small bowel. It is safe, and the diagnostic yield is approximately 80%. The study adds to the Indian data on CE. Author contribution statement KA and MJ collected the data and wrote the manuscript. BST and AM critically appraised the manuscript with their suggestions. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.