Capsule endoscopy was first used in 2001 and is now widely accepted. Capsule endoscopy is a noninvasive method of evaluating the small intestine, which is critical to diagnose small intestinal disease [
Abdominal pain is a common complaint of patients visiting a gastroenterology department, and patients often require examination of the gastric cavity and possibly the small intestine. We investigated the diagnostic efficacy of MGCE to evaluate both the gastric cavity and small intestine in pediatric patients with abdominal pain.
We enrolled patients aged 6–18 years of age with a complaint of abdominal pain to undergo MGCE examination between January 2017 and October 2018. We excluded the following: patients with dysphagia, suspected or known gastrointestinal stenoses or obstruction, or congenital gastrointestinal malformations or intestinal fistula; patients in poor general condition and unable to tolerate the examination; and patients with pacemakers, defibrillators, or other implants that could be affected by external magnetic fields. All patients and their guardians provided informed consent, and the study was approved by the Ruijin Hospital Ethics Committee.
We used the system manufactured by Ankon Technologies Co. Ltd. (Wuhan, China), which was approved by the China Food and Drug Administration in 2013. The system consists of capsules, a control system, a portable recorder, and a capsule locator. The capsule weights 5 g and has a diameter of only
Gastrointestinal preparation began at 8 pm the day before examination. For patients older than 10 years or weighing >40 kg, 2000 mL of polyethylene glycol (PEG) solution was administered as for adults. Patients ≤10 years old or weighing ≤40 kg received 25 mL/kg of PEG. Oliva et al. [
We recorded the following patient information: age, sex, weight, and indications for MGCE. Wearing the portable recorder, patients swallowed the capsule. Lying on the bed, patients were asked to change position from left lateral, to supine, to right lateral, then sitting, if necessary. During the examination, some patients required additional water to extend the gastric cavity. An experienced examiner controlled the capsule to evaluate the gastric cavity and, if possible, the bulb and descending duodenum. Following the gastric cavity examination, patients continued to wear the portable recorder for more than 7 hours to permit evaluation of the small intestine. We asked all patients whether they were willing to undergo the examination again. Additionally, for those who had undergone conventional gastroscopy, we asked which examination they preferred. All patients were followed for 2 weeks to record adverse events and to confirm capsule excretion.
For patients who failed to swallow the capsule, a transparent hood-assisted endoscopic delivery device was used to deliver the capsule into the esophagus. When the capsule remained in the stomach for >1.5 hours, we added gastric motility-promoting drugs. If the capsule still failed to pass through the pylorus, we used an endoscopic snare loop to deliver the capsule to the duodenum (Figure
(a) Transparent hood-assisted endoscopic delivery (capsule endoscope loaded on the tip of gastroscope by a transparent hood); (b) endoscopic snare loop.
Continuous data were summarized as mean and standard error, mean and range, or median and range, and categorical data were presented as proportions. Comparisons between groups were performed using Student’s
We enrolled 48 patients: 32 (66.7%) boys and 16 (33.3%) girls with a mean age of
The mean gastric evaluation time, which was defined as the time the examiner manipulated the capsule, was 8.5 minutes (range, 5–17 minutes). The mean gastric transit time, defined as the time the capsule remained in the gastric cavity, was 54 minutes (range, 5–254 minutes), and the mean small intestinal transit time was 246 minutes (range, 86–561 minutes). In nine (18.6%) patients, the examiner controlled the capsule passing through the pylorus to detect the bulb and descending duodenum, but in two patients, gastric motility-promoting drugs, namely, metoclopramide, 2.5–5 mg by intramuscular injection, were used, and in 1 patient, both gastric motility-promoting drugs and the endoscopic snare loop were used to deliver the capsule into the duodenum. At the end of the examination, the capsule had not passed the ileocecal valve in three patients.
We assessed the cleanliness of the gastric cavity as excellent (gastric mucosa appearing clear and almost no bubbles or mucus affecting the field of vision; score, 100%), good (a small amount of bubbles or mucus affecting the field of vision; score, 75%), fair (moderate amount of bubbles or mucus affecting the field of vision; score, 50%), poor (a large amount of bubbles or mucus affecting the field of vision; score, 25%). In which, excellent and fair were satisfactory. The median cleanliness of the gastric cardia, fundus, body, angle, antrum, and pylorus was 100 (75, 100) %, 75 (50, 100) %, 75 (50, 100) %, 100 (75, 100) %, 100 (50, 100) %, and 100 (75, 100) %, respectively. And the cleanliness of the gastric cardia, fundus, body, angle, antrum, and pylorus was assessed satisfactorily in 100%, 85.4%, 89.6%, 100%, 97.9%, and 100% of patients, respectively. In general, the cleanliness of the distal cavity was better than in the proximal cavity. Statistically, the cleanliness of the cardia, angle, antrum, and pylorus was significantly better than that of the fundus and body (
We also subjectively assessed the proportion of visible mucosa as a range from 0% to 100%. The percentage of visible mucosa in the gastric cardia, fundus, body, angle, antrum, and pylorus was 84.8%, 83.8%, 88.5%, 87.7%, 95.2%, and 99.6%, respectively, with better visualization distally compared with proximally generally. Statistically, the visualization of pylorus was significantly better than the others (
We found 19 gastrointestinal tract lesions in 18 patients (37.5%), although some of the lesions might have been unrelated to the patients’ abdominal pain. One patient (2.1%) had an erosion above the dentate line and was finally diagnosed with reflux esophagitis. Lesions were detected in the stomach in three patients (6.3%), namely, a polyp, a protuberant lesion, and congestion and edema. These three patients were finally diagnosed as having a gastric polyp, ectopic pancreas, and congestive exudative gastritis, respectively. Fifteen patients (23.0%) had lesions in the small intestine including four with duodenal ulcers. Eight patients had ulcers in the jejunoileum: two patients had ulcers in the jejunum only, two in the ileum only, and four in both the jejunum and ileum; six of these eight patients were eventually diagnosed with Crohn’s disease. The patient with the stomach polyp also had ileal congestion and edema and was diagnosed as having ileitis. A bulging lesion resembling a bowel segment protruding from the intestinal wall was detected at the jejunoileal junction in one patient, which was suspected to be intestinal duplication. In another patient, we found two openings in the lower ileum; the capsule passed through one opening, and the other opening was suspected to be a diverticulum (Table
Endoscopy findings and presumed diagnosis.
Location of findings | No | Endoscopy findings | No | Presumed diagnosis | No |
---|---|---|---|---|---|
Esophagus | 1 | Esophageal erosion | 1 | Reflux esophagitis | 1 |
Stomach | 3 | Gastric polyp | 1 | Gastric polyps | 1 |
Gastric eminence lesion | 1 | Ectopic pancreas | 1 | ||
Gastric congestion and edema | 1 | Congestive exudative gastritis | 1 | ||
Duodenum | 4 | Duodenal ulcer | 4 | Duodenal ulcer | 4 |
Jejunoileum | 11 | Jejunal ulcer | 2 | Jejunal ulcer | 1 |
Ileal ulcer | 2 | Jejunoileal ulcers | 1 | ||
Ileal and jejunal ulcers | 4 | Crohn’s disease | 6 | ||
Ileal congestion and edema | 1 | Ileitis | 1 | ||
Ileal diverticulum | 1 | Ileal diverticulum | 1 | ||
Small intestinal eminence lesions | 1 | Intestinal duplication | 1 | ||
Total | 19 | Total | 19 | Total | 19 |
MGCE findings. 1: reflux esophagitis; 2: ectopic pancreas; 3: duodenal ulcers; 4: diverticulum; 5-8: Crohn’s disease.
In patients with only abdominal pain, the diagnostic yield was 27.6%, while in patients with additional complaints, the diagnostic yield was 52.6%.
Of the six patients with abdominal pain and vomiting, three (50%) had endoscopic abnormalities, and two of these patients were finally diagnosed as having Crohn’s disease and one was diagnosed as having congestive exudative gastritis. Of the seven patients with abdominal pain and gastrointestinal bleeding, five (71.2%) had endoscopic lesions (four with small intestinal ulcers and one with a diverticulum). In the three patients with abdominal pain accompanied by diarrhea and gastrointestinal bleeding, one patient was diagnosed as having Crohn’s disease and one as having a duodenal ulcer.
All patients successfully swallowed the capsule. Three patients required metoclopramide to help the capsule pass through the pylorus, and one also required the endoscopic delivery device. All patients felt that the MGCE procedure was comfortable and acceptable, and none had complaints during or after the examination. All patients were willing to undergo the procedure again. Of the 29 patients who had undergone traditional gastroscopy previously, all preferred MGCE. All patients excreted the capsule within 2 weeks.
The Ankon MGCE system had a high diagnostic accuracy for gastric lesions compared with conventional gastroscopy, in several studies. Zou et al. [
In addition to accuracy, another issue of concern is the cleanliness and visualization of the gastric cavity with MGCE. In our study, the cleanliness of all parts of the gastric cavity in most patients was sufficient to clearly evaluate the gastric cavity. In some patients, mucus, bubbles, food residue, and bile affected the cleanliness. However, by changing the patient’s position, mucus floats to a different location and no longer blocks the capsule’s camera; antifoaming agents help greatly for the bubbles [
Traditional gastroscopy is considered to provide better evaluation of the duodenum because MGCE evaluates the duodenum passively. In our study, in 18.6% of patients, we pushed the capsule through the pylorus to explore the duodenum, but this is not done routinely. We believe that higher success rates for visualizing the duodenum are possible if we make the effort in every patient.
Compared with conventional gastroscopy, MGCE can avoid the discomfort caused by intubation and the adverse effects of narcotic drugs. In our study, all patients had a comfortable experience, and none experienced adverse events during follow-up. MGCE appears to be an excellent choice for pediatric patients, especially for those afraid of undergoing conventional gastroscopy.
In the pediatric patients with abdominal pain in our study, Crohn’s disease was the most common diagnosis, followed by duodenal ulcers. Some studies [
MGCE is safe, convenient, and tolerable for evaluating the gastric cavity and small intestine in pediatric patients. Overall, MGCE can effectively diagnose pediatric patients with abdominal pain.
The data used to support the findings of this study are available from the corresponding authors upon request.
The authors declare no competing interests.
This work was supported by the National Natural Science Foundation of China (81672719, 81870385).