Endoscopy-Assisted Capsule Endoscopy in Patients with Swallowing Disorders

 

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Capsule endoscopy (CE) has greatly facilitated the diagnosis of small-bowel lesions in patients with obscure gastrointestinal bleeding [1]. It was recently reported by Hollerbach et al. [2] that endoscopically assisted video capsule endoscopy facilitates the investigation of the small bowel in patients with functional gastric outlet obstruction. Swallowing difficulties, which are not uncommon in elderly patients, may also make it difficult to carry out CE [3]. To avoid this, we have successfully tested a modified approach to CE in these patients.

An 80-year-old man with a 1-year of history of iron-deficiency anemia requiring frequent blood transfusions underwent several negative endoscopic and radiographic examinations. Routine CE was contraindicated, as the patient had severe dysphagia secondary to a cerebrovascular insult. It was therefore decided to deposit the video capsule (M2A, Given Imaging Ltd., Israel) in the duodenum. As capsules preloaded in a Dormia basket tend to be deflected when passing the pharynx, with the risk of causing mucosal damage and being dropped into the larynx, an overtube was used as a precaution. After the patient had received intravenous premedication with midazolam and butylscopolamine bromide, the stomach was intubated with a video gastroscope, with an overtube 52 cm in length. The tube was advanced into the stomach, and the endoscope was withdrawn. A Roth retrieval net was inserted into the endoscope and the capsule was placed in it. The system was inserted into and through the overtube (Figure [1]) and moved through the stomach, and the capsule was released into the distal duodenum (Figure [2]). The intubation system was then removed and a standard CE examination started, which identified three angiodysplasias in the proximal jejunum. All of these later underwent argon plasma coagulation through a push enteroscope.

Figure 1 The gastroscope and Roth net, with the activated capsule, before insertion into the overtube.

Figure 2 a Gastroscopic image of the duodenum with the capsule in the Roth retrieval net. b Capsule image of the duodenum through the net.

This well-tolerated technique of endoscopy-assisted CE has also been used in two other patients with dysphagia, without any complications. The approach is simple and only requires a couple of minutes. We would suggest that this endoscopy-assisted technique can facilitate the performance of CE in patients with nonobstructive swallowing disorders, and that it may eliminate dysphagia as a contraindication to capsule endoscopy.

References

• 1 Lewis B, Goldfarb N. The advent of capsule endoscopy: a not-so-futuristic approach to obscure gastrointestinal bleeding.  Aliment Pharmacol Ther. 2003;  17 1085-1096
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• 2 Hollerbach S, Kraus K, Willert J. et al . Endoscopically assisted video capsule endoscopy of the small bowel in patients with functional gastric outlet obstruction.  Endoscopy. 2003;  35 226-229
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• 3 Borgström P S, Ekberg O. Pharyngeal dysfunction in the elderly.  J Diagn Imaging. 1988;  2 74-81
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E. Tóth, M. D., Ph. D.

Dept. of Medicine

Malmö University Hospital
S-205 02 Malmö
Sweden

Fax: + 46-40-337878

Email: ervin.toth@medforsk.mas.lu.se