Physical activity during video capsule endoscopy correlates with shorter bowel transit time

Introduction: Video capsule endoscopy (VCE) is the preferred modality for assessment of the small bowel mucosa, but it is limited by the battery lifespan of the device and reliance on bowel motility for propulsion. Lack of physical activity has been proposed as a potential cause of incomplete studies. The aim of this study was to prospectively investigate the association between physical activity and VCE completion and bowel transit times. Methods: All ambulatory outpatients undergoing VCE were assessed for inclusion. After consent, relevant clinical characteristics were obtained. At the time of ingestion of a VCE with standard 8 hour battery, a sealed pedometer was attached to the patient. At the conclusion of the procedure, the step-count was recorded. VCE completion was assessed by univariable and multivariable logistic regression models which included pedometer step count (500 steps as one unit). Total transit time was analyzed by univariable and multivariable Cox proportional hazards models. Gastric and small bowel transit times were assessed in univariable Cox proportional hazards models. The hazard ratios (HR) indicate the “hazard” of completion, such that hazard ratios greater than 1 indicate reduced transit time. Results: One hundred patients were included, with mean age 50.9 years and 64% female. VCE was completed in 93 patients (93%). The mean step count was 3,125 steps (SD = 2,070). Pedometer step count was significantly associated with shorter total transit times (HR = 1.08; 95% CI 1.02, 1.14), gastric transit times (HR = 1.06; 95% CI 1.01, 1.11) and small bowel transit times (HR = 1.06; 1.01, 1.12) in univariable analysis. Step counts remained significantly associated with total transit times in the multivariable model (HR = 1.09; 95% CI 1.03, 1.16; Table 1). In univariable and multivariable analysis, step count was not significantly associated with VCE completion (p = 0.17 and 0.15 respectively; Table 2).Table 1: Multivariable Cox proportional hazards model for video capsule endoscopy total transit timeTable 2: Multivariable logistic regression for video capsule endoscopy completionConclusion: In the first study to use a validated tool to directly measure physical activity, higher step counts during outpatient VCE correlated with shorter bowel transit times but were not significantly associated with study completion. We suspect the decrease in bowel transit times did not translate into higher rates of study completion due to the high baseline completion rate. Given the lack of negative side effects, we recommend encouraging physical activity during VCE studies.

Purpose: To investigate the effect of opioids on bowel transit time and completion rate in hospitalized patients undergoing video capsule endoscopy (VCE). Methods: We performed a retrospective review of all hospitalized patients undergoing VCE since the implementation of a new electronic medical record (October 15, 2011 - March 31, 2013). Exclusion criteria included endoscopic placement. Demographic data, medical history, medications and indication for VCE were collected from the medical record. Gastric transit time (GTT), small bowel transit time, total transit time (TTT) and study completion were collected from the VCE report. Transit times were summarized using median and inter-quartile range (IQR) and compared by log-rank analysis. Multivariable logistic regression modeling was utilized with resultant odds ratios (OR) and 95% confidence intervals (95% CI). Results: We performed 157 VCE that met study criteria. Patients without opioids within 48 hours of the VCE had a median GTT of 12 min, IQR 7 - 35 and patients with opioids within 48 hours had a median GTT of 42 min, IQR 12 - 87 (p=0.007). Patients without opioid use were also less likely to have a GTT > 45 min (22% vs. 46%, p= 0.005). There was a trend toward lower total transit times (TTT) in patients not receiving opioids, with a median TTT of 246 min, IQR 189 - 362 compared to 286 min, IQR 212 - > 480 in the opioids group (p= 0.13). There was not a significant difference in VCE completion rate (82% vs. 74%, p=0.28) or gastric capsule retention (2% vs. 5%, p=0.67) between the groups. Demographic data and medical history were similar. After multivariable logistic regression modeling, opioid use was associated with GTT > 45 min (OR 2.96, 95% CI 1.33, 6.61, p=0.008). Conclusion: Opioid use within 48 hours of VCE was significantly associated with prolonged GTT in hospitalized patients. We also found a significant increase in GTT > 45 minutes with opioid use, a benchmark that has been associated with incomplete VCE in previous studies. Although we did not find a significant difference in completion rate with opioid use (perhaps related to sample size), we noted a trend toward longer TTT. This data suggests hospitalized patients should avoid opioids during the 48 hours prior to VCE ingestion to decrease incidence of prolonged GTT.

Purpose: Lubiprostone, a selective activator of type 2 chloride channels, is approved for treatment of chronic idiopathic constipation and constipation predominant IBS. It has been suggested that lubiprostone has a prokinetic effect. This investigation was designed to evaluate lubiprostone as a preparation and propulsive agent for small bowel capsule endoscopy. Methods: The PillCam Small Bowel (SB) capsule endoscopy system (Given Imaging, Yoqneam, Israel) utilizing the PillCam SB1 capsule and Rapid 5 software platform was used. The study was designed as a double blinded placebo-control trial in 40 healthy adults to compare gastric transit time (GTT), small bowel transit time (SBTT), and small bowel cleansing preparation. The study subjects received lubiprostone 24 mcg or placebo 30 minutes prior to PillCam capsule ingestion. Capsule endoscopy studies were read by two independent investigators unaware of the study medication received and differences in interpretation were resolved by consensus. Anatomical landmarks were identified and GTT and SBTT were calculated. Overall preparation assessment of the proximal, mid, and distal small bowel was determined by a 4 step scale. Percentage of visualized bowel was determined by review of 10 minute video segments at 1 hr intervals after the capsule passed through the pylorus. Results: In the lubiprostone group (N = 20), 2 subjects did not pass the capsule through the pylorus in the 8 hr battery time of the capsule. An additional 3 capsules did not pass into the colon. In the placebo group (N = 20), all capsules passed into the small bowel, but 1 did not pass into the colon. The subjects in which the capsules did not pass into the small bowel were excluded from the small bowel analysis. In the subjects that the capsules did not reach the colon, the SBTT was determined by total number of minutes subtracted from the gastric emptying time for each subject. The mean GTT in the lubiprostone group was 126 minutes and 43 minutes in the placebo group (P= 0.0095). The mean SBTT in the lubiprostone group was 208 minutes and 228 minutes in the placebo group (P= 0.249). The overall preparation assessment of the small bowel was not statistically significant between the 2 groups in the proximal, mid or distal small bowel (p- = 0.119-proxmial, 0.118-mid, 0.121-distal). There was no significant difference in lubiprostone vs. placebo in the percentage of visualized small bowel. Conclusion: Lubiprostone had a significant increase in GTT but did not result in a significant decrease in SBTT as compared to placebo. The administration of lubiprostone prior to capsule ingestion did not result in improved overall preparation of the small bowel for capsule endoscopy or increase the percentage of visualized small bowel.

During capsule endoscopy (CE) studies, the complete examination rate (CER) can be increased by prolonging capsule battery life or reducing gastric transit time (GTT) and/or small bowel transit time (SBTT). However, despite enhanced battery life, 10% of studies remain incomplete. Previously studied interventions to reduce SBTT and enhance CER have produced conflicting results. We hypothesize that this may be a consequence of an insufficiently potent stimulus of small bowel motility. To examine whether potent stimulation of the cephalic response of digestion during small bowel CE reduces GTT and/or SBTT and thus increases the CER. A single-blind randomized trial was performed to evaluate the effect of bacon sham feeding on GTT, SBTT and CER. Baseline characteristics were similar between 63 sham fed patients and 59 controls. The median GTT was 17min (9-65) in the bacon group and 25min (14-55) in the control group. The median SBTT was 199min (119-316) and 222min (151-287), respectively. Cox proportional hazards model demonstrated no significant difference between groups for GTT (rate ratio 1.03, 95% CI 0.71-1.51, P=0.87) or SBTT (rate ratio 1.02, 95% CI 0.70-1.49, P=0.93). Although the taste of bacon was considered favorably by 72% of participants, taste did not correlate with GTT (ρ=0.03, P=0.83) or SBTT (ρ=-0.115, P=0.33). The CER was 91 and 95% in the bacon and control groups, respectively (P=0.35). Bacon sham feeding has no effect on GTT, SBTT or CER and cannot be recommended in clinical practice.

INTRODUCTION:Optimizing the accuracy of colon capsule endoscopy (CCE) requires high completion rates. To prevent incomplete CCE, we aimed to identify predictors associated with slow CCE transit times.METHODS:In this population-based study, participants received CCE with a split-dose polyethylene glycol bowel preparation and booster regimen (0.5 L oral sulfate solution and 10 mg metoclopramide if capsule remained in stomach for > 1 hour). The following predictors were assessed: age, sex, body mass index (BMI), smoking, coffee and fiber intake, diet quality, physical activity, dyspeptic complaints, stool pattern, history of abdominal surgery, medication use, and CCE findings. Multivariable logistic and linear regressions with backward elimination were performed.RESULTS:We analyzed 451 CCE procedures with a completion rate of 51.9%. The completion rate was higher among older participants (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.04–2.28, P = 0.03) and participants with a changed stool pattern (OR 2.27, 95% CI 1.20–4.30, P = 0.01). Participants with a history of abdominal surgery had a lower completion rate (OR 0.54, 95% CI 0.36–0.80, P = 0.003). Participants with higher BMI had faster stomach, small bowel, and total transit times (β = −0.10, P = 0.01; β = −0.14, P = 0.001; β = −0.12, P = 0.01). A faster small bowel transit was found in participants with a changed stool pattern (β = −0.08, P = 0.049) and the use of metoclopramide (β = −0.14, P = 0.001). Participants with high fiber intake had a slower colonic transit (β = 0.11, P = 0.03).DISCUSSION:Younger age, unchanged stool pattern, history of abdominal surgery, low BMI, and high fiber intake resulted in slower CCE transit times and lower completion rates. In future practice, these factors can be considered to adjust preparation protocols.

To determine the effect of oral erythromycin on gastric and small bowel transit time of capsule endoscopy. Consecutive patients who underwent capsule endoscopy during the 16-mo study period were either given 250 mg oral erythromycin, 1 h prior to swallowing the capsule endoscope or nothing. The gastric and small bowel transit time, and the small bowel image quality were compared. Twenty-four patients received oral erythromycin whereas 14 patients were not given any prokinetic agent. Patients who received erythromycin had a significantly lower gastric transit time than control (16 min vs 70 min, P = 0.005), whereas the small bowel transit time was comparable between the two groups (227 min vs 183 min, P = 0.18). Incomplete small bowel examination was found in three patients of the control group and in one patient of the erythromycin group. There was no significant difference in the overall quality of small bowel images between the two groups. A marked reduction in gastric transit time was noted in two patients who had repeat capsule endoscopy after oral erythromycin. Use of oral erythromycin significantly reduces the gastric transit time of capsule endoscopy.

There are no reports to prove the repeatability of gastric transit time (GTT) and small bowel transit time (SBTT) in capsule endoscopy (CE). To clarify the repeatability and factors that affect GTT/SBTT in CE. We analyzed the data of 150 healthy subjects from our previous randomized controlled trial that compared small intestinal injuries between two 14-day treatment groups: 1) celecoxib and 2) loxoprofen + lansoprazole. Correlation of GTT/SBTT with pre- and post-treatment CE was analyzed. In addition, the associations of pre-treatment CE SBTT with physical factors, post-treatment CE SBTT and the presence of small intestinal mucosal injuries were analyzed. Analyses of 148 subjects pre-treatment CE and 146 subjects post-treatment CE were performed. There were no significant differences between mean GTT and SBTT before and after treatment. Both GTT (𝜌 = 0.22, p < 0.01) and SBTT (𝜌 = 0.47, p < 0.0001) showed positive correlations between pre- and post-treatment CE. In pre-treatment CE, physical factors and the presence of small intestinal mucosal injury had no associations with SBTT. Moderate correlation in SBTT and slight correlation in GTT were shown on repeated CE. The factors affecting SBTT were not clarified in this analysis.

Factors That Delay Transit Time of Wireless Capsule Endoscopy

To determine if longer battery life improves capsule endoscopy (CE) completion rates. A retrospective study was performed at a tertiary, university-affiliated hospital in Vancouver, Canada. Patients who underwent CE with either PillCam™ SB2 or SB2U between 01/2010 and 12/2013 were considered for inclusion. SB2 and SB2U share identical physical dimensions but differ in their battery lives (8 h vs 12 h). Exclusion criteria included history of gastric or small bowel surgery, endoscopic placement of CE, interrupted view of major landmarks due to technical difficulty or significant amount of debris, and repeat CE using same system. Basic demographics, comorbidities, medications, baseline bowel habits, and previous surgeries were reviewed. Timing of major landmarks in CE were recorded, and used to calculate gastric transit time, small bowel transit time, and total recording time. A complete CE study was defined as visualization of cecum. Transit times and completion rates were compared. Four hundred and eight patients, including 208 (51.0%) males, were included for analysis. The mean age was 55.5 ± 19.3 years. The most common indication for CE was gastrointestinal bleeding (n = 254, 62.3%), followed by inflammatory bowel disease (n = 86, 21.1%). There was no difference in gastric transit times (group difference 0.90, 95%CI: 0.72-1.13, P = 0.352) and small bowel transit times (group difference 1.07, 95%CI: 0.95-1.19, P = 0.261) between SB2U and SB2, but total recording time was about 14% longer in the SB2U group (95%CI: 10%-18%, P < 0.001) and there was a corresponding trend toward higher completion rate (88.2% vs 93.2%, OR = 1.78, 95%CI 0.88-3.63, P = 0.111). There was no statistically significant difference in the rates of positive findings (OR = 0.98, 95%CI: 0.64-1.51, P = 0.918). Extending the operating time of CE may be a simple method to improve completion rate although it does not affect the rate of positive findings.

BackgroundIn up to 30 percent of small bowel capsule endoscopy procedures, the capsule does not reach the cecum within recording time. A prolonged gastric transit time has been recognized as a risk factor for incomplete capsule endoscopy. The aim of this study was to analyze if a single dose of orally administered erythromycin prior to capsule endoscopy results in a higher completion rate compared to orally administered domperidone.MethodsSingle centre, non-concurrent prospective cohort study, 649 capsule endoscopy procedures were included. Cecal completion rates, gastric and small bowel transit times and diagnostic yield were analyzed.Results239 patients received erythromycin, 410 patients received domperidone. The cecal completion rate was 86% after erythromycin versus 80% after domperidone (p = 0.03). After excluding known risk factors for incomplete capsule endoscopy such as hospitalization and previous abdominal surgery, erythromycin still resulted in an increased completion rate (p = 0.04). Median gastric transit time was lower after erythromycin compared to domperidone (13 min versus 22 min, p < 0.001). Median small bowel transit times were similar in both groups (236 min versus 248 min, p = 0.21).ConclusionsIn this study, the largest to date on this subject, the cecal completion rate was higher with erythromycin than with domperidone, but there was no difference in the diagnostic yield.

Capsule endoscopy (CE) has been demonstrated to be safe and well tolerated in adults with suspicion of small intestinal diseases with negative results of gastroscopy and colonoscopy. However, its value in pediatric patients has not yet been well studied. This study aimed to evaluate the results and safety of CE in pediatric patients with suspicion of small bowel disorders. There were 16 consecutive children and adolescents (12 boys, 4 girls) and 15 adults (9 men, 6 women) referred to us for suspected small bowel diseases from August 2002 to September 2005. Among the pediatrics, six patients were less than 10 years old. Technique for capsule placement, gastric transit time, small bowel transit time, excretion time of capsule endoscopy, capsule findings, and complications were recorded. All 16 pediatric patients described that the capsule was easy to swallow except for three children. Finally we delivered the capsule under gastroscopy with overtube for these three children. No capsule retention occurred during our study. Median recording time was 7 h 44 min (range 6 h 51 min-9 h 11 min). Median gastric transit time was 83.5 min (range 4-296 min). Median small bowel transit time was 270 min (range 142-484 min). Median excretion time of capsule was 33.9 h (range 12-96 h). There was no significant difference in excretion time of capsule, gastric transit time and small bowel transit time between pediatric patients and adult patients (P > 0.05). CE was positive in 12 patients, including Crohn's disease (4), hemangioma (2), angiodysplasia (2), Meckel diverticulum (1), polyp (1), aphthous ulcer in ascending colon (1), and cobblestone appearance of ileal mucosa. CE has been performed safely in a small series of pediatric patients after ingestion or endoscopic placement of the capsule. The high yield of abnormal findings was comparable to those of adult patients.

Prognostic Value of Late Heart Rate Recovery After Treadmill Exercise

Right lateral position does not affect gastric transit times of video capsule endoscopy: a prospective study

Obscure small bowel bleeding is defined as gastrointestinal bleeding (GIB) that is unidentifiable with esophagogastroduodenoscopy and a colonoscopy with video capsule endoscopy (VCE) being the next gold standard step for evaluation. Small bowel transit time (SBTT) is a metric of a VCE study that is defined as the time the capsule takes to travel through the small intestine. To determine if SBTT within the VCE study, correlates to overall detection of obscure small bowel bleeds. Furthermore, we attempted to identify any existing correlation between SBTT and re-bleeding after a negative VCE study. This is a single center retrospective analysis of VCE studies performed for overt and occult GIB at Einstein Medical Center, Philadelphia, between 2015 and 2019. Inclusion criteria primarily consisted of patients 18 years or older who had a VCE study done as part of the workup for a GIB. Patients with incomplete VCEs, poor preparation, or with less than 6 mo of follow up were excluded. A re-bleeding event was defined either as overt or occult within a 6-mo timeframe. Overt re-bleeding was defined as Visible melena or hematochezia with > 2 gm/dL drop in hemoglobin defined an overt re-bleeding event; whereas an unexplained > 2 gm/dL drop in hemoglobin with no visible bleeding defined an occult re-bleed. Results indicated that there was a significant and positive point biserial correlation between SBTT of 220 min and detection of a bleeding focus with a statistically significant p value of 0.008. However, the area under the curve was negligible when trying to identify a threshold time for SBTT to discriminate between risk of re-bleeding events after a negative VCE. In terms of SBTT and association with accuracy of VCE finding a bleeding focus, 220 min was found to be adequate transit time to accurately find a bleeding focus, when present. It was found that no threshold SBTT could be identified to help predict re-bleeding after a negative VCE.

Background: Consistent evidence has linked excess body fatness (EBF), typically measured in large epidemiologic studies using body mass index (BMI), with a higher risk of 13 types of cancer. Whether physical activity mitigates any of the excess risk associated with EBF is unclear—as few studies have examined the joint association between BMI and physical activity. Methods: We examined the joint association of BMI and physical activity on the risk of 12 of the 13 EBF-related cancers (excluding meningioma and including esophagus [adenocarcinoma], gastric cardia, colon and rectum, liver, gallbladder, pancreas, postmenopausal breast, corpus uteri, ovary, kidney [renal cell], thyroid, and multiple myeloma) among 70,658 men and 72,209 postmenopausal women (median age: 63 years) without a history of cancer at study entry in the Cancer Prevention Study II Nutrition Cohort (1992-2013). Multivariable Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for the individual and joint associations between BMI (kg/m2) and recreational physical activity (MET-hours/week) at study entry and first cancer incidence. Results: Between 1992-2013, 3,860 men and 9,001 women were diagnosed with an EBF-related cancer. Compared to normal weight (BMI 18.5-&amp;lt;25 kg/m2), overweight (25-&amp;lt;30 kg/m2) was associated with a modest increased risk of EBF-related cancer (men: HR 1.12; 95% CI: 1.04, 1.21; women: HR 1.13; 95% CI: 1.08, 1.19) and obesity (≥30 kg/m2) with a stronger risk (men: HR 1.48; 95% CI: 1.34, 1.63; women: HR 1.48; 95% CI: 1.40, 1.57). Higher levels of physical activity (&amp;gt;15 vs. &amp;gt;0-&amp;lt;7.5 MET-hrs/wk) were associated with a lower risk for EBF-related cancer among women (HR: 0.90; 95% CI: 0.85-0.95) but less so among men (HR: 0.96; 95% CI: 0.88, 1.04). Among women, there was no evidence of interaction between physical activity and BMI for the risk of EBF-related cancer (P-interaction=0.59); however, there was suggestive evidence that the excess risk associated with overweight was modestly mitigated by the highest level of physical activity (HR: 1.00; 95% CI: 0.91, 1.10). Among men, there was some evidence of an interaction between BMI and physical activity on risk (P-interaction=0.06) with the higher risk associated with overweight limited to those who were inactive (HR: 1.27; 95% CI: 1.08, 1.49). However, risk was higher for obese men irrespective of physical activity level. Conclusion: Our results suggest that higher levels of recreational physical activity may offset a small amount of the increased risk of EBF-related cancer among overweight men and women. However, physical activity does not appear to mitigate the strong effect of obesity (BMI ≥30 kg/m2) on risk of EBF-related cancers, thus reinforcing the importance of maintaining a healthy body weight even if physically active. Citation Format: Maret L. Maliniak, Susan M. Gapstur, Lauren E. McCullough, Erika Rees-Punia, Mia M. Gaudet, Caroline Y. Um, Mark A. Guinter, Elizabeth A. Fallon, Alpa V. Patel. Joint associations of physical activity and body mass index and the risk of excess body fatness-related cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 961.