During CCE, as the capsule is not equipped to insufflate the colon, aspirate liquids, wash the mucosal surface and move actively along the gut, the cleansing protocol cannot be restricted to the time before the procedure but has to be continued during it. The cleansing protocol for CCE aims at (a) adequately cleansing the colonic mucosa, (b) filling the colon lumen with clear liquids to improve mucosal visualization and to decrease the number of air bubbles and (c) facilitating capsule progression so that it reaches the anal verge before battery life ends. Therefore, before capsule ingestion, patients are invited to follow a regimen of preparation specifically designed for CCE (Table 5.1) [2, 3].

As for conventional colonoscopy, a low residue diet is often recommended during the 3–5 days before the bowel cleansing protocol itself. The aim was to decrease the amount of solid stool in the colon and thus reinforce the lavage effect of polyethylene glycol (PEG) solutions. On the other hand, when CCE is considered, the recent experience seems to suggest that a clear liquid diet prescribed on the day before the procedure might improve the quality of bowel cleansing and consequently the diagnostic yield of CCE. Therefore, diet recommendations (i.e., liquid diet the day before, low residue diet 3–5 days before colon capsule endoscopy ) have generally been adopted in the studies published so far.

Starting from the experience with bowel cleansing for colonoscopy, lavage solutions with large volumes (4L) of polyethylene glycol (PEG) solutions have been used in most studies with colon capsule endoscopy . Very little experience with lower doses of PEG is currently available and, therefore, low-dose of PEG is not recommended. Studies demonstrating the equivalence of lower volumes cleansing and PEG protocols for conventional colonoscopies can not be extended to CCE.

A split regimen of PEG is recommended: 2 L of PEG on the day before and 2 L on the day of CCE. This split (2 + 2) regimen of preparation seems to be more acceptable by the patients and equally effective in terms of colon cleanliness [3].

To meet the specific goals of bowel cleansing for colon capsule discussed above, phosphate (NaP) boosters have been added to the classical PEG and diet recommendations used for conventional colonoscopy. The role of boosters administered during capsule progression is not limited to increase and/or maintain colonic cleanliness but includes also a propulsive effect by means of a volume effect allowing the capsule to move in a watery environment. The propulsive effect of NaP boosters results in an effective colon capsule transit along the small and large bowels with a higher rate of capsule expulsion within the limited operating time of the capsule battery. A low NaP dose (total, 45 or 55 mL) is recommended: usually 30 ml of NaP at the small-bowel detection (1st booster) and 15–25 ml of NaP (2nd booster) 2 h after the 1st booster [3].

Prokinetics have been added to the protocol of bowel preparation of CCE mainly to stimulate the progression of the capsule in the upper gut, especially the stomach. Administration of prokinetics should be limited to cases where the capsule had not entered the small bowel within 1 h after ingestion [3].

One of the main advantages of CCE for patients is the option of out-of-clinic colonoscopy. This is possible because the data recorder can be programmed to synchronize with the prescribed regimen to alert the patient with an audible and vibrating signal to view the number displayed on its LCD screen. The “home procedure” was recently evaluated in a prospective study in which 41 patients with known or suspected colonic disease s were offered CCE to be performed as an out-of clinic procedure [4]. According to data recorder-registered alerts, 14 patients (34 %) required a single booster only, 27 patients (66 %) required two boosters and 13 patients (32 %) required a suppository. Patient compliance to data recorder alerts was 100 %. During the procedure, 16 patients (39 %) called the physician/clinic from home for doubts and/or need of explanations. In all the cases, the reason for the call was managed by telephone. In 85 % of the cases, the colon capsule was excreted within the battery operating time. The results of this study suggest that as an out-of-clinic procedure, CCE is feasible and easily performed. A home-based procedure may be associated with better acceptability and potentially with increased adherence to colorectal cancer screening.

CCCE is feasible, safe and appears to be accurate when used in average risk subjects [3]. Patients with non-alarm symptoms do not appear to be at increased risk of colorectal neoplasia. For this reason, noninvasive tests may be proposed in this setting as an alternative to colonoscopy. Among noninvasive tests, however, imaging tests might be preferred over nonimaging tests (i.e., fecal tests), because of the ability to detect non-neoplastic conditions that may be regarded as clinically useful (e.g., vascular malformation s). Among noninvasive imaging tests, CCE may be applicable to this setting for the considerations of its feasibility, safety and accuracy.