Mike Thomson Wireless capsule video‐endoscopy (WCE or VCE) has been used in pediatric small bowel investigation for over 20 years and is a standard tool for the investigation of pathologies such as occult/obscure GI bleeding (see Chapter 31) (Figure 15.1), polyp syndromes (see Chapter 43) (Figure 15.2), small bowel Crohn’s (see Chapter 25) (Figure 15.3), and less common pathologies such as diaphragm disease (also known as chronic mucosal ulcerating and stenosing enteropathy, CMUSE) and tumors (Figures 15.4 and 15.5). It is now preferred by most as the tool for investigating a Meckel’s diverticulum (Figure 15.6) and has become standard in IBD staging complementing magnetic resonance enteroclysis (MRE) and standard endoscopy (see Figure 15.3). Possible NSAID enteropathy can be excluded (Figure 15.7), which includes Crohn’s‐like lesions and ulcerating stenoses (Figure 15.8), and the patchy nature of celiac disease can be identified (Figure 15.9). Ideally, it is accompanied by a sister therapeutic technique such as double‐balloon enteroscopy (DBE) (see Chapter 14) or occasionally intraoperative enteroscopy (IOE). This chapter will deal with the practicalities of WCE in children and is not meant as an atlas – there are already very good texts that cover this area in more detail than space allows here. Figure 15.1 Occult bleeding from an angiodysplasia. Figure 15.2 Jejunal Peutz–Jeghers polyp. Figure 15.3 (a) Crohn’s disease. (b) A follow‐up study in a 16‐year‐old male treated for Crohn’s disease shows inflammatory pseudopolyps in the ileum. (c) Small bowel Crohn’s disease. (d) Flat Crohn’s‐like lesion in jejunum. Figure 15.4 CMUSE or diaphragm disease. Figure 15.5 Lymphoma. Bowel preparation and starving/oral intake instructions are those which are standard for the unit’s ileocolonoscopy (see Chapter 12). Often a detergent such as simethicone can be given 1–2 hours before the procedure to decrease bubbles and alalow better mucosal visualization – 10 mL under 5 years, 20 mL 5–10 years and 40 mL over 10 years. A propulsion agent may be employed such as metoclopramide or domperidone but this is not usually necessary unless profound dysmotility is previously identified – and unfortunately is rarely beneficial anyway. Children under 12 but over 8 can be taught to swallow the capsule by a number of weeks of tutoring to swallow jelly beans whole – it is very patient‐specific in terms of whether or not they will swallow a capsule and generally we would have a back‐up plan of placing the child first on the afternoon endoscopy list and starved in order to place the capsule endoscopically if swallowing fails, thereby avoiding the waste of a capsule. In this approach gastro nurses are invaluable in persuasion. Figure 15.6 Meckel’s diverticulum. Figure 15.7 NSAID lesions. Figure 15.8 Crohn’s aphthoid ulcers and stricture. Figure 15.9 Celiac disease. Introduction of the capsule endoscopically into the small bowel in children who will not swallow it is well described and used to involve a Roth net but this caused too much mucosal trauma – we now have a capsule delivery device (Acorn®, US Endoscopy) which is “front‐loaded” onto the endoscope and introduced with a normal endoscopic approach (Figure 15.10). This can occur down to 6 months of age. In practice, the flashing end of the capsule is loaded towards the endoscope – this allows the endoscopist to identify when the capsule is deployed; if they can no longer see the flashing of the capsule, then the capsule has left the device. Once the endoscope has entered the stomach, the capsule and delivery device can be protruded away from the end of the endoscope (prior to which the endoscopist’s view is somewhat obscured in the esophagus by the capsule) and a better view towards the pylorus may be allowed. On insertion of the capsule and delivery device through the pylorus in older children with a more spacious duodenal bulb, negotiation into the more distal part of the duodenum may be possible. However, in younger children and infants, deployment in the first part of the duodenum may be necessary. In this scenario it is important to avoid deployment against the distal wall of the duodenum which will result in the capsule being “half‐deployed” and kept in the delivery device. A trick to avoid this is to give a small IV dose of buscopan (hyoscine) to relax the duodenum and to have only the first third of the capsule protruding into the duodenum. When one is trying to detect occult/obscure GI bleeding lesions, it is recommended to avoid taking duodenal biopsies which will bleed and the blood will often travel down the small intestine with the capsule, causing visual confusion. Figure 15.10 Methods of “front‐loading” the PillCamTM onto a gastroscope. (a) Using a Roth net. (b) Endoscopic insertion of a PillCam with the capsule delivery device. (c,d) Illustration of how the US Endoscopy device deploys the capsule. One must be aware of the technology of the receiving module, ensuring that it is kept close to the patient at all times. Otherwise if no signal is detected, it will cease to record after a period of time and not reinitialize. Of course, the battery must be fully charged and the patient details input into the base station. A number of models are now available from different companies; there is little to choose between the alternatives and price may differ. Most give a recording life on one battery of up to 15 hours which is more than sufficient to traverse the small bowel in all children, barring the presence of strictures. The question of whether or not to use a dissolvable practice capsule in case of strictures has been debated. It is common in adults but in children it is not generally useful. This is because of two considerations: first, to place such a capsule in young children would need a separate GA for endoscopic insertion and second, a video capsule can stay in the small bowel for months if not years in reported experience without causing any problems at all. In any event, if the capsule did cause obstructive symptoms then it would highlight an area that would require surgery anyway. If really necessary, it is possible to remove a capsule from the mid‐small bowel by DBE. If it is arrested due to an inflammatory pathology, it is our experience that with antiinflammatories such as steroids which diminish the inflammatory component of such a stricture/stenosis, the capsule will often pass uneventfully. If obstructive symptoms occur then it is likely that the stricture would have needed surgery in any case. Although nonsteroidal antiinflammatory drugs are less commonly employed in children, they commonly cause mucosal injury, including ulcerations that mimic Crohn’s disease. The drug‐induced lesions may include mucosal breaks, focal ulcerations (see Figure 15.7) and circumferential, ulcerated strictures – so‐called diaphragm disease or CMUSE. However, in children this is more usually a congenital condition of prostaglandin receptor abnormal function (see Figure 15.4). Histological confirmation of specific diagnoses suggested by capsule endoscopy should thus always be considered, where feasible – this can be provided reliably by balloon enteroscopy. Crohn’s disease may be identified occurring only in the small bowel by WCE and may be missed by MRE (see Figures 15.3 and 15.8). Among adult patients, capsule endoscopy has been shown to be highly efficient in detecting small bowel tumors that were missed by conventional endoscopic and imaging methods, including push enteroscopy. Although small bowel malignancies are rare in children, inherited gastrointestinal polyposis disorders such as Peutz–Jeghers syndrome are not uncommonly seen by pediatric gastroenterologists and surgeons. Complications of these tumors include small bowel intussusception, bleeding and less commonly malignancy (see Figure 15.2). Polyp syndrome surveillance recommendations are published as guidelines by ESPGHAN for children. Polyps less than 15 mm are better detected with capsule endoscopy than MRE or other imaging studies. The available data thus suggest that capsule endoscopy should replace barium X‐rays, MRI, and push enteroscopy for the identification of small bowel polyps in the pediatric age group. The localization software is not useful for guiding the clinician to the possibility of reaching a polyp for removal endoscopically, but calculation of the time from pylorus to polyp divided by total small bowel transit time can give a percentage of the length of the small bowel which the polyp might be located at enteroscopy. Obscure/occult bleeding is defined as bleeding of unknown origin that persists or recurs (recurrent or persistent visible bleeding, iron‐deficiency anemia with positive fecal occult blood testing) after a negative initial or primary endoscopy (upper and/or lower endoscopy). The source of bleeding is frequently located in the small bowel and may result from a number of conditions, including vascular lesions and inflammatory lesions, or tumors (see Figures 15.1, 15.5 and 15.6). Imaging techniques for evaluation of the small bowel are relatively insensitive for intestinal bleeding lesions that are flat, small, infiltrative, or inflammatory. Angiography and radioisotope bleeding scans are insensitive in the absence of brisk active bleeding but CT angiography is occasionally helpful, as is a plain CT scan for lesions such as gastric duplication cysts, etc. As noted above, intraoperative enteroscopy is the most thorough but also the most invasive means to visualize the small bowel. Double‐balloon enteroscopy is the best method that offers the possibility of achieving complete small bowel enteroscopy and providing therapy without the need for laparoscopy/laparotomy. Capsule endoscopy is a useful tool for diagnosing and monitoring the effects of therapy in patients with blue rubber bleb nevus syndrome. Bleeding from small bowel varices in pediatric cases with portal hypertension is also described, allowing banding by enteroscopy if in the proximal small bowel (see Figure 15.7). WCE may be considered the diagnostic modality of choice for lesions such as angiodyplasia of the small bowel including Diuelafoy’s and Meckel’s diverticulum (see Figure 15.6), in which isotope scanning is notoriously unreliable. NSAID lesions are also sources of jejunal bleeding (see Figure 15.8). For celiac disease, histological diagnosis remains the gold standard although recent guidelines suggest that with a tissue transglutaminase 10 times the upper limit of normal in a symptomatic child, a biopsy may not be necessary. WCE can show typical features macroscopically with scalloping or a mosaic appearance but it is unlikely to replace formal upper GI endoscopy (see Figure 15.9). In addition to the more common indications that have been discussed above, capsule endoscopy is likely to prove clinically useful for a variety of other potential disorders of the small bowel in the pediatric age group (see Table 15.1). The identification of abnormal but undiagnosed findings on small bowel imaging is a worthwhile indication for capsule study. Pathologies that have been uncovered include small bowel lymphomas (see Figure 15.5), intestinal lymphangiectasia (Figure 15.11), chronic intermittent intussusception and ischemic bowel disease as causes of recurrent abdominal pain by capsule endoscopy in adolescent patients (Figure 15.12). Capsule endoscopy can also be useful to ascertain the intestinal manifestations of immunodeficiency disorders and graft‐versus‐host disease, but in essence these remain histology‐dependent diagnoses. Table 15.1 Potential indications for capsule endoscopy in pediatric patients Figure 15.11 Intestinal lymphangiectasia. Figure 15.12 Intestinal intussusception. An esophageal capsule with a video camera at each end has been developed but its utility in children is somewhat limited as it is mainly aimed at esophageal cancer and varices in adults (Figure 15.13). Hence it has not drawn advocates in pediatric GI circles. Equally, the colon capsule has not caught on in children (Figure 15.14), possibly because this WCE device, with a delayed onset of imaging in order to focus on the colon, requires extremely good bowel prep. In addition, the difference in the pediatric GI world is that we require tissue diagnosis generally with biopsies. One interesting recent evolution is that of the magnetically controlled capsule that can be maneuvered in the upper GI tract by a strong external magnet (Figure 15.15). This may be helpful in acute GI bleeding scenarios; the disadvantage is that it requires the stomach to be filled with fluid for good 100% mucosal visualization and once into the duodenum, it can pass rapidly, precluding decent images of the duodenal cap. Once in the duodenum, the magnet is no longer strong enough to coax it back into the first part of the duodenum or stomach. Figure 15.13 Images obtained with an esophageal capsule. Figure 15.14 Colon capsule. Figure 15.15 Mechanism for magnetic capsule propulsion. Wireless capsule endoscopy represents an extraordinary technical innovation in diagnostic gastrointestinal endoscopy. As in adult patients, it opens new horizons that permit an accurate and noninvasive approach to identify occult lesions in the small bowel in children and adolescents. It can be successful even in infants as young as 6 months old.
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Wireless capsule endoscopy
Introduction
Practical approach
Pediatric experience and pathologies
Small bowel IBD and inflammatory pathologies
Polyposis syndromes and other intestinal tumors
Occult or obscure intestinal bleeding
Other indications
Small bowel inflammatory disorders
Crohn’s disease; celiac disease; food allergic or eosinophilic enteropathies; intestinal vasculitis/angiodysplasia; Henoch–Schönlein purpura; drug‐induced mucosal injury (nonsteroidal antiinflammatory or chemotherapy); radiation enteropathy; graft‐versus‐host disease; intestinal transplantation
Small bowel polyps and tumors
Peutz–Jeghers syndrome; other familial and nonfamilial polyposes; lymphoma, leiomyoma, carcinoid and other tumors
Occult or obscure intestinal bleeding
Including vascular malformations, portal hypertension, and small bowel varices
Abnormal findings on small bowel imaging
Unexplained malabsorption and protein‐losing enteropathies
Intestinal lymphangiectasia, allergic or congestive enteropathies, etc.
Chronic abdominal pain with high suspicion of small bowel pathology
Motility disorders – not an ideal modality but may give an impression
Esophageal disorders
Esophagitis, Barrett’s esophagus, esophageal varices 
Recent developments
Conclusion
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