Pediatric INSIGHTS - Winter '06Children's Hospital of Pittsburgh of UPMC

The PillCam SB can detect objects less than 0.1mm in size, giving it a significant advantage over a small bowel follow-through, which usually cannot detect objects smaller
than 0.5mm


Capsule Endoscopy


A pill-shaped camera that is swallowed by their patients is allowing gastroenterologists at Children’s Hospital of Pittsburgh of UPMC to examine in remarkable detail the entire length of the small intestine for evidence of Crohn’s Disease and other disorders that may escape notice using more conventional endoscopic and radiological diagnostic tests.

The technology, known as capsule endoscopy, closes a significant diagnostic gap by taking a series of more than 50,000 full-color, highly detailed video images of the small intestine, including the long, twisting, difficult-to-evaluate region from the duodenum to the colon.

Children’s began using capsule endoscopy this year.

Until then, the small intestine had exposed the limitations of conventional, non-surgical tests. An upper endoscopy cannot extend into the large, middle region of the small intestine, which a colonoscopy also fails to reach. Push endoscopy can probe more of the small intestine, but it is technically difficult, risks perforating the intestinal wall and is not often performed on children. The most common test is the small bowel follow-through, but its x-ray images often fail to detect more subtle evidence of a disorder.

Capsule endoscopy has emerged as superior technology, providing a painless way to thoroughly examine the small intestine and enhance early detection of serious disorders.

“We have about a half-dozen patients so far who have had their Crohn’s Disease diagnosed this way after there was no indication of disease from radiographic tests,” said Mark E. Lowe, MD, PhD, Children’s chief of the Division of Pediatric Gastroenterology.

Capsule endoscopy is typically ordered after conventional diagnostic tests – including an upper endoscopy, colonoscopy and small bowel follow-through – fail to confirm an incomplete or suspected diagnosis.

Dr. Lowe estimates that Children’s will use capsule endoscopy 30-40 times a year, most often to search for evidence of Crohn’s Disease or to locate the source of gastrointestinal bleeding. Other less common uses may include identifying polyps in the small intestines of patients with certain genetic disorders and more precisely defining a diseased area of the small intestine in patients whose conditions warrant surgical intervention.

PillCam Images Chron's Disease Celiac Disease Gastro-intestinal Bleeding Small bowel tumors

The PillCam™ SB helps Children’s Hospital’s specialists to diagnose and treat patients with gastrointestinal disorders of the small intestine such as Crohn’s disease (photo 1), celiac disease (photo 2), gastrointestinal bleeding (photo 3), inflammatory bowel disease, small bowel tumors (photo 4) and NSAID related injuries.

The PillCam™ SB capsule glides down the GI track taking approximately 50,000 images of the small bowel. These images are transmitted to and then stored on a recorder belt worn by the patient for an eight hour period. Upon completion, the physician views the images using the Given Imaging workstation and RAPID® software to make a diagnosis.

Children’s uses a capsule endoscopy system called the The PillCam™ SB developed by Israel-based Given Imaging that includes the capsule shaped camera, a data recorder and specialized software that enables physicians to download, view and work with the images on a computer workstation.

The PillCam™ SB itself is 11mm x 26mm, about twice the diameter of a Tylenol capsule, and has its own light source, battery and transmitter. It shoots high-resolution color images, has a field of view of 140 degrees and, most importantly, is highly sensitive. The camera can detect objects less than 0.1 mm in size, giving it a significant advantage over a small bowel follow-though, which usually cannot detect objects smaller than 0.5 mm.

For most children age 10 years or older, the procedure is simple. They swallow the tiny camera, go about their day and return to their gastroenterologist’s office in about eight hours. Most say the capsule, which is coated to reduce friction, is easier to swallow than a regular pill. For younger children unable to swallow the camera, it is placed on the tip of an endoscope and inserted into the small intestine, a technique that requires mild sedation.

Whether swallowed or placed, natural peristalsis moves the camera through the small intestine, where it transmits images at a rate of two frames per second as it travels, or about 57,000 images during an eight-hour examination period.

Meanwhile, the ambulatory procedure allows patients to leave their gastroenterologist’s office and go about their normal activities. A period of fasting is required to prepare for the procedure. However, patients can resume eating a few hours after they ingest the camera. As they go about their day, each patient carries a portable data recording device holstered to a belt that is worn around the waist. The recorder gathers the signals sent by the camera through an array of sensors that are taped to the child’s abdomen. The exam ends for the patient when, after wearing the recorder for about eight hours, it is returned to the gastroenterologist. The camera is naturally excreted and is not reused.

The stored images are downloaded from the recorder to a computer configured with software that enables gastroenterologists to view, edit, archive and e-mail the video images, in addition to saving individual images and short video clips.

These images have already significantly improved early diagnosis of difficult-to-confirm cases of Crohn’s Disease. It gives gastroenterologists the evidence they need to begin treatment early rather than empirically treat a patient of a suspected disorder or wait until the disease declares itself when symptoms progress.

With a disease such as Crohn’s, that means an opportunity to more quickly address issues ranging from bone thinning to delays in growth and puberty that significantly affect the well-being of young patients. “The advantage is that we can improve the quality of their lives – get them to grow again, get them nutritionally rehabilitated and get them into puberty,” Dr. Lowe said. “In pediatrics, that makes a big difference.”