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Page 2 of 7 O’Grady et al. Mini-invasive Surg 2022;6:34 https://dx.doi.org/10.20517/2574-1225.2022.22

Conclusion: Our data suggest that 14-day PFA may no longer be required for small bowel capsules not seen to
reach the large bowel. Advice regarding symptoms of capsule retention and precaution with magnetic resonance
imaging, similar to current UGI capsule advice, may suffice. This may reduce the burden on radiology imaging slots
and, in particular, eliminate unnecessary radiation exposure and repeat hospital attendance for patients.

Keywords: Video capsule endoscopy, plain film abdomen, asymptomatic

INTRODUCTION
[1]
Video capsule endoscopy (VCE), first introduced in 2000 , has an increasingly important role in
gastrointestinal investigation. Most commonly used to identify a cause for anemia, occult gastrointestinal
bleed, or characterize and diagnose small bowel inflammatory bowel disease, capsule endoscopy technology
has recently advanced to allow video inspection of the entire gastrointestinal tract. Procedures and patient
preparation are tailored to the intestinal segment of interest, similar to standard endoscopy. Upper
gastrointestinal tract, small bowel, and colon capsules all require specific fasting and preparation to achieve
diagnostic mucosal views. Following the procedure, however, a more standard approach may be reasonable.
The ingested capsule, regardless of recording segment, consists of similar components and size and must
pass through the alimentary canal. Thus, post-procedure protocols should not differ in asymptomatic
patients.

Capsule retention, defined as visible retention on plain film of abdomen (PFA) after 14 days, is the most
concerning risk with VCE . Overall retention risk is low, estimated at 1.2%-4.63% , and in the absence of
[3]
[2]
symptoms of capsule retention, conservative management is often advocated. Retention risk may be
reduced further by careful patient selection, use of patency capsules, and screening of referrals by an
experienced capsule endoscopist. Currently, if a small bowel capsule is not seen to pass into the caecum
during the recording window [Figure 1], a follow-up PFA is advised by current guidelines 14 days later to
identify possible capsule retention [2,4,5] . With regard to upper gastrointestinal tract capsule endoscopy, the
protocol and recording window does not allow sufficient time to observe the capsule passing into the
caecum. A routine PFA in these cases is, for the most part, unnecessary and would significantly burden both
radiology departments and patients with repeat hospital attendance. In addition, as capsule endoscopy
services continue to expand, in part driven by the COVID-19 pandemic, a large increase in capsule
procedures may be expected.

To reduce the effect an increased capsule endoscopy service may have on radiology departments and to
improve patient care and experience, we aimed to standardize the post-capsule procedural advice offered to
[2]
asymptomatic patients. We considered whether current guideline advice of a 14-day PFA in small bowel
capsule cases not seen to reach caecum is no longer required in the absence of patient symptoms, similar to
upper gastrointestinal tract VCE. To better inform patient safety, future risk of retention, and address
whether PFA is required or a more generalized patient information booklet may suffice, a review of all small
bowel VCE and PFAs performed within our unit over a five-year period was performed.

METHODS
In an Irish single-center tertiary referral unit for VCE, all cases of small bowel VCE requiring PFA
performed over a five-year period were reviewed. This included PFAs evaluating possible capsule retention
14 days post VCE as well as those undergoing luminal patency capsule testing. Cases where a cause for
capsule retention was identified on the capsule recording and those with symptoms suggestive of
obstruction were evaluated separately, as they did not undergo 14-day follow-up PFA but rather definitive